CMS/EIP Fiscal Report Center: 57
Services beginning 01/01/2022 ending 03/31/2022 Date of Report:04/16/2022 Page: 1
List order: No List
Payclass Filters:TPIN
Eligibility Filter:Part C (excluding not eligible)
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 1 3.500000 129.5000 37.0000
Subtotal (Total Children Is Unduplicated) 1 3.500000 129.5000 37.0000
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Screening, Eval, and Assessment,Class #02
AUDE-92582-CONDITIONED PLAY AUDIOMETRY 1 1.000000 63.1400 63.1400
EXIT-EXIT-EXIT ASSESSMENT 1 2.000000 100.0000 50.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 4 7.500000 562.5000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 1 1.000000 75.0000 75.0000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 4 7.500000 416.2500 55.5000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 48 88.500000 6587.5000 74.4350
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 14 26.500000 1987.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 11 19.500000 1412.5000 72.4359
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 62 115.000000 6282.5000 54.6304
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 5 9.500000 712.5000 75.0000
OCTH-97165-OT EVAL LOW COMPLEXITY 2 2.000000 102.1000 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 5 5.000000 255.2500 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 6 6.000000 306.3000 51.0500
SPCH-92523GT-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 3 3.000000 153.1500 51.0500
Subtotal (Total Children Is Unduplicated) 91 296.000000 19118.2900 64.5888
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1 7.000000 350.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 3 11.000000 785.8400 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 6 23.000000 1315.6000 57.2000
PHY-97110GT-PT SESSION BY LICENSED PT 2 5.000000 357.2000 71.4400
PHY-97110HM-PT SESSION BY PT ASST 1 8.000000 457.2800 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 11 56.000000 4000.6400 71.4400
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 3 7.500000 535.8000 71.4400
SPL-92507HMGT-SPL THERAPY SESSION BY SLP ASST 1 7.000000 400.4000 57.2000
Subtotal (Total Children Is Unduplicated) 28 124.500000 8202.7600 65.8856
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Total 424.000000 27450.5500 64.7419
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Number of Children (Unduplicated) With at Least One Service 111
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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 2 3.000000 195.7500 400.0000
D 0 0.000000 0.0000 0.0000
S 2 2.000000 102.1000 102.1000
H 0 0.000000 0.0000 0.0000
T 21 46.000000 2848.8800 2848.8800
191 372.000000 24252.7700 6182.7700
Other 1 1.000000 51.0500 51.0500
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Total 217 424.000000 27450.5500 9584.8000