CMS/EIP Fiscal Report Center: 10
Services beginning 10/01/2021 ending 12/31/2021 Date of Report:02/04/2022 Page: 1
List order: No List
Payclass Filters:MED
Eligibility Filter:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 2239 7116.000000 263273.5000 36.9974
Subtotal (Total Children Is Unduplicated) 2239 7116.000000 263273.5000 36.9974
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Screening, Eval, and Assessment,Class #02
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 3 3.000000 70.5000 23.5000
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 3 3.000000 43.7400 14.5800
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 3 3.000000 29.3700 9.7900
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 3 3.000000 86.1600 28.7200
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 3 3.000000 62.6700 20.8900
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 5 9.500000 712.5000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 9 16.500000 1198.5000 72.6364
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 1.500000 112.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 2 4.000000 300.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 3 6.000000 450.0000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 2 3.500000 262.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 4 8.000000 444.0000 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 7 11.500000 638.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 101 191.000000 14325.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 133 254.000000 19050.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 36 64.500000 4837.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 28 51.500000 3862.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 17 30.000000 2250.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 35 63.000000 4725.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 112 213.000000 11821.5000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 126 236.500000 13125.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 38 60.000000 4500.0000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 20 38.500000 2887.5000 75.0000
OCTH-97166-OT EVAL MODERATE COMPLEXITY 22 22.000000 1123.1000 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 1 1.000000 51.0500 51.0500
PSTH-97162-PT EVAL MODERATE COMPLEXITY 10 10.000000 510.5000 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 1 1.000000 51.0500 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 2 2.000000 102.1000 51.0500
SPCH-92524-BEHAV & QUAL ANALYSIS OF VOICE AND RES 19 19.000000 969.9500 51.0500
SPCH-92524GT-BEHAV & QUAL ANALYSIS OF VOICE AND RES 1 1.000000 51.0500 51.0500
Subtotal (Total Children Is Unduplicated) 369 1333.500000 88654.2400 66.4824
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 553 5454.000000 272700.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 379 2313.250000 115662.5000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 186 1097.500000 78405.4000 71.4400
OCCT-97530GT-OT SESSION BY LICENSED OT 9 46.750000 3339.8200 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 60 310.250000 17746.3000 57.2000
OCCT-97530HMGT-OT SESSION BY OT ASST 2 3.500000 200.2000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 277 1425.000000 101802.0000 71.4400
PHY-97110GT-PT SESSION BY LICENSED PT 21 51.250000 3661.3000 71.4400
PHY-97110HM-PT SESSION BY PT ASST 11 20.000000 1143.2000 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 239 1312.500000 93592.3200 71.3084
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 36 133.500000 9537.2400 71.4400
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 1 6.000000 343.2000 57.2000
SPL-92508HA-GROUP SPL SESSION PER CHILD 2 4.000000 55.5200 13.8800
Subtotal (Total Children Is Unduplicated) 1226 12177.50000 698189.0000 57.3343
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Total 20627.000000 1050116.7400 50.9098
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Number of Children (Unduplicated) With at Least One Service 2448
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Center 10
Flag Claims Units Chgs Paid
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R 74 56.250000 2081.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 9029 7875.750000 327143.5000 0.0000
P 77 111.750000 6671.0100 1672.4000
D 31 27.500000 1384.8900 0.0000
S 15 24.500000 1168.9600 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
3949 12214.000000 699456.8800 0.0000
Other 427 317.250000 12210.2500 0.0000
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Total 13602 20627.000000 1050116.7400 1672.4000