CMS/EIP Fiscal Report Center: 53
Services beginning 04/01/2022 ending 06/30/2022 Date of Report:08/08/2022 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 1.250000 46.2500 37.0000
Subtotal (Total Children Is Unduplicated) 1 1.250000 46.2500 37.0000
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Screening, Eval, and Assessment,Class #02
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-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 2.000000 150.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 2 4.000000 300.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 2 4.000000 222.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 5 8.500000 637.5000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 18 32.500000 2437.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 2 4.000000 300.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 14 23.500000 1762.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 12 19.500000 1462.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 4 8.000000 444.0000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 22 38.000000 2100.7500 55.2829
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 2 3.000000 225.0000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 2.000000 150.0000 75.0000
SPL-92526-TREATMENT OF SWALLOWING DYSFUNCTION 1 6.000000 315.4200 52.5700
Subtotal (Total Children Is Unduplicated) 54 163.000000 11006.7800 67.5263
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 1 1.000000 1194.2800 1194.2800
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 1 3.000000 150.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 43 155.000000 7750.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 39 97.750000 4887.5000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 14 56.000000 4000.6400 71.4400
OCCT-97530GT-OT SESSION BY LICENSED OT 8 22.250000 1589.5400 71.4400
OCCT-97530TL-OT SESSION BY LICENSED OT 1 1.000000 71.4400 71.4400
PHY-97110-PT SESSION BY LICENSED PT 14 84.500000 6036.6800 71.4400
PHY-97110GT-PT SESSION BY LICENSED PT 12 31.250000 2232.5000 71.4400
SENS-V5264-EARMOLD 1 2.000000 36.0000 18.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 35 143.250000 10233.7800 71.4400
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 27 73.750000 5268.7000 71.4400
Subtotal (Total Children Is Unduplicated) 133 670.750000 43451.0600 64.7798
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Total 835.000000 54504.0900 65.2744
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Number of Children (Unduplicated) With at Least One Service 168
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Center 53
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 1.250000 46.2500 0.0000
H 0 0.000000 0.0000 0.0000
T 22 22.000000 1100.0000 1100.0000
739 793.750000 52089.8000 0.0000
Other 17 17.000000 1193.0400 0.0000
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Total 780 834.000000 54429.0900 1100.0000