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:Program Patients
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-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 1 2.000000 150.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 75 133.000000 9875.0000 74.2481
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 24 43.500000 3262.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 24 41.500000 3033.2500 73.0904
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 104 186.500000 10225.7500 54.8298
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 12 20.500000 1537.5000 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) 142 464.000000 30219.7900 65.1289
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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 592.000000 38552.0500 65.1217
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Number of Children (Unduplicated) With at Least One Service 162
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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 22 47.500000 2932.1300 2848.8800
290 538.500000 35271.0200 6182.7700
Other 1 1.000000 51.0500 51.0500
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Total 317 592.000000 38552.0500 9584.8000