CMS/EIP Fiscal Report Center: 57
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-92567-TYPMANOMETRY (IMPEDANCE TESTING) 1 1.000000 9.0800 9.0800
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 1 1.000000 27.8300 27.8300
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 1 1.000000 16.7000 16.7000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 3 5.500000 412.5000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 2 3.500000 262.5000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 1 1.500000 62.5000 41.6667
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 1 2.000000 150.0000 75.0000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 5 8.500000 421.7500 49.6176
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 75 125.000000 8833.4200 70.6674
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 17 29.000000 1950.0000 67.2414
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 16 23.000000 1625.0000 70.6522
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 94 153.500000 7913.7800 51.5556
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 15 24.500000 1787.5000 72.9592
OCTH-97166GT-OT EVAL MODERATE COMPLEXITY 1 1.000000 51.0500 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 6 6.000000 306.3000 51.0500
OCTH-97167GT-OT EVAL HIGH COMPLEXITY 1 1.000000 51.0500 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 11 11.000000 561.5500 51.0500
SPCH-92523GT-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 2 3.000000 153.1500 51.0500
Subtotal (Total Children Is Unduplicated) 133 402.000000 24646.7100 61.3102
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 270 1715.500000 85775.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 23 127.250000 6362.5000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 4 12.000000 857.2800 71.4400
OCCT-97530GT-OT SESSION BY LICENSED OT 4 10.500000 750.1200 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 7 39.000001 2230.8000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 1 3.000000 214.3200 71.4400
PHY-97110GT-PT SESSION BY LICENSED PT 2 9.000035 642.9600 71.4397
PHY-97110HM-PT SESSION BY PT ASST 5 33.000000 1886.2800 57.1600
PHY-97110HMGT-PT SESSION BY LICENSED PT ASST 1 2.000000 114.3200 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 15 87.000015 6215.2800 71.4400
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 3 8.500000 607.2400 71.4400
Subtotal (Total Children Is Unduplicated) 294 2046.750051 105656.1000 51.6214
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Total 2448.750051 130302.8100 53.2120
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Number of Children (Unduplicated) With at Least One Service 390
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Center 57
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 13 11.140472 760.9300 1155.6800
D 2 2.000000 130.5000 0.0000
S 4 4.000000 204.2000 204.2000
H 0 0.000000 0.0000 0.0000
T 624 2033.609579 103325.9600 99596.0100
220 398.000000 25881.2200 6864.2200
Other 0 0.000000 0.0000 0.0000
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Total 863 2448.750051 130302.8100 107820.1100