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:TPIN
Eligibility Filter:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Screening, Eval, and Assessment,Class #02
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 15 16.000000 314.3900 19.6494
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 15 16.000000 232.5700 14.5356
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 15 15.000000 146.1400 9.7427
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 15 15.000000 430.9200 28.7280
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 13 14.000000 273.0800 19.5057
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 2.000000 150.0000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 2 4.000000 300.0000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 1 2.500000 187.5000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 1 2.500000 187.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 2.000000 111.0000 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 1 1.500000 83.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 58 120.500000 9037.5000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 84 168.500000 12637.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 12 26.000000 1950.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 20 37.500000 2812.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 9 17.500000 1312.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 18 32.500000 2437.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 54 109.000000 6049.5000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 64 127.000000 7020.7500 55.2815
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 22 51.000000 3825.0000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 21 49.000000 3675.0000 75.0000
OCTH-97166-OT EVAL MODERATE COMPLEXITY 11 12.000000 561.5500 46.7958
OCTH-97166GT-OT EVAL MODERATE COMPLEXITY 1 1.000000 51.0500 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 2 1.500000 76.5700 51.0467
PSTH-97162-PT EVAL MODERATE COMPLEXITY 4 4.000000 204.2000 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 1 1.000000 51.0500 51.0500
SPCH-92523GT-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 1 1.000000 51.0500 51.0500
SPCH-92524-BEHAV & QUAL ANALYSIS OF VOICE AND RES 22 24.250000 1084.8000 44.7340
SPCH-92524GT-BEHAV & QUAL ANALYSIS OF VOICE AND RES 1 1.000000 51.0500 51.0500
SPCH-92610-EVAL OF ORAL,PHARYNGEAL SWALLOWING FUNC 1 1.000000 44.5500 44.5500
Subtotal (Total Children Is Unduplicated) 227 875.750000 55349.9700 63.2029
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1 3.000000 150.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 1 8.000000 400.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 1 5.000000 50.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 145 751.750000 52006.8700 69.1811
OCCT-97530GT-OT SESSION BY LICENSED OT 8 37.250000 2661.1400 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 29 178.000000 10215.1600 57.3885
PHY-97110-PT SESSION BY LICENSED PT 180 955.250000 65793.3700 68.8756
PHY-97110GT-PT SESSION BY LICENSED PT 16 52.000000 3589.8600 69.0358
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 212 1154.250000 80609.3000 69.8370
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 21 79.250000 5590.1800 70.5385
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 6 38.500000 2202.2000 57.2000
Subtotal (Total Children Is Unduplicated) 382 3262.250000 223268.0800 68.4399
-----------------------------------------------------------------------------------------------------------------------
Total 4138.000000 278618.0500 67.3316
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 553
-----------------------------------------------------------------------------------------------------------------------
Center 10
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 0 0.000000 0.0000 0.0000
P 1396 2201.250000 146713.0000 146522.9600
D 1 1.000000 71.4400 0.0000
S 8 11.000000 521.5300 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
1053 1913.250000 130517.8300 0.0000
Other 6 11.500000 794.2500 0.0000
---------------------------------------------------------
Total 2464 4138.000000 278618.0500 146522.9600