CMS/EIP Fiscal Report Center: 54
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-92555-SPEECH AUD THRESHOLD (DETECTION) 1 1.000000 14.5800 14.5800
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 1 1.000000 9.7900 9.7900
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 1 1.000000 28.7200 28.7200
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 1 1.000000 20.8900 20.8900
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 1 2.000000 150.0000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 1 2.000000 150.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 17 31.500000 2362.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 22 43.000000 3225.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 14 26.000000 1950.0000 75.0000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 23 42.500000 2358.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 2.000000 150.0000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 20 37.500000 2812.5000 75.0000
Subtotal (Total Children Is Unduplicated) 58 192.500000 13382.7300 69.5207
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 6 11.000000 555.1400 50.4673
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 2 2.250000 0.0000 0.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 11 17.500000 875.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 56 272.500000 13625.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 11 35.000000 2500.4000 71.4400
OCCT-97530GT-OT SESSION BY LICENSED OT 29 80.000000 5750.9200 71.8865
OCCT-97530TL-OT SESSION BY LICENSED OT 1 1.000000 71.4400 71.4400
OCCT-97530TLGT-OT SESSION BY LICENSED OT 1 1.000000 71.4400 71.4400
PHY-97110-PT SESSION BY LICENSED PT 10 12.000000 857.2800 71.4400
PHY-97110GT-PT SESSION BY LICENSED PT 20 75.750000 5411.5800 71.4400
PHY-97110TL-PT SESSION BY LICENSED PT 1 1.000000 71.4400 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 13 20.000000 1428.8000 71.4400
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 27 128.500000 9180.0400 71.4400
Subtotal (Total Children Is Unduplicated) 144 657.500000 40398.4800 61.4426
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Total 850.000000 53781.2100 63.2720
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Number of Children (Unduplicated) With at Least One Service 180
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Center 54
Flag Claims Units Chgs Paid
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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 0 0.000000 0.0000 0.0000
D 0 0.000000 0.0000 0.0000
S 2 2.000000 121.4400 0.0000
H 0 0.000000 0.0000 0.0000
T 124 134.740000 7202.2700 7202.2700
610 671.260000 43642.8600 0.0000
Other 41 42.000000 2814.6400 0.0000
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Total 777 850.000000 53781.2100 7202.2700