CMS/EIP Fiscal Report Center: 53
Services beginning 07/01/2021 ending 06/30/2022 Date of Report:08/08/2022 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 2 1.000000 37.0000 37.0000
Subtotal (Total Children Is Unduplicated) 2 1.000000 37.0000 37.0000
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Screening, Eval, and Assessment,Class #02
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 1 1.000000 23.5000 23.5000
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 1 1.000000 14.5800 14.5800
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 3 3.000000 86.1600 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-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 2 4.000000 300.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 2 4.000000 300.0000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 2 4.500000 337.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 5 10.500000 582.7500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 3 4.500000 337.5000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 61 114.500000 8775.0000 76.6376
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 3 6.000000 450.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 41 76.500000 5737.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 2 4.000000 300.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 28 46.500000 3487.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 5 9.500000 527.2500 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 97 178.500000 9898.5000 55.4538
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 14 26.000000 1950.0000 75.0000
SPL-92526-TREATMENT OF SWALLOWING DYSFUNCTION 1 6.000000 315.4200 52.5700
Subtotal (Total Children Is Unduplicated) 156 510.000000 34119.0500 66.9001
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 3 4.000000 2620.4000 655.1000
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 1 3.000000 150.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 53 235.250000 11762.5000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 121 876.000000 43800.0000 50.0000
INTR-T1013-INTERPRETER 1 2.000000 150.0000 75.0000
OCCT-97530-OT SESSION BY LICENSED OT 30 144.750000 10340.9400 71.4400
OCCT-97530GT-OT SESSION BY LICENSED OT 36 229.500000 17192.5200 74.9129
OCCT-97530TL-OT SESSION BY LICENSED OT 1 8.000000 1014.3200 126.7900
OCCT-97530TLGT-OT SESSION BY LICENSED OT 3 2.750000 262.8800 95.5927
PHY-97110-PT SESSION BY LICENSED PT 23 235.750000 16841.9800 71.4400
PHY-97110GT-PT SESSION BY LICENSED PT 21 139.023665 9931.8507 71.4400
SENS-V5264-EARMOLD 2 4.000000 72.0000 18.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 50 313.450000 22393.5400 71.4421
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 64 550.030000 39353.9600 71.5488
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 1 1.000000 71.4400 71.4400
Subtotal (Total Children Is Unduplicated) 267 2748.503665 175958.3307 64.0197
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Total 3259.503665 210114.3807 64.4621
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Number of Children (Unduplicated) With at Least One Service 320
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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 19 17.480000 2748.8000 1769.5900
D 64 67.500000 4558.2800 0.0000
S 14 16.000000 1096.5200 0.0000
H 0 0.000000 0.0000 0.0000
T 326 330.454800 16934.1200 16934.1200
2052 2201.568865 142358.4807 0.0000
Other 605 624.000000 42230.6800 0.0000
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Total 3080 3257.003665 209926.8807 18703.7100