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:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 4 6.000000 222.0000 37.0000
Subtotal (Total Children Is Unduplicated) 4 6.000000 222.0000 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 3 6.000000 450.0000 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 3 6.000000 450.0000 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 7 14.000000 777.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 6 10.000000 750.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 79 144.000000 10987.5000 76.3021
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 4 8.000000 600.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 58 103.500000 7762.5000 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 35 57.500000 4312.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 10 17.500000 971.2500 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 129 231.000000 12812.2500 55.4643
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 15 27.500000 2062.5000 75.0000
SPL-92526-TREATMENT OF SWALLOWING DYSFUNCTION 1 6.000000 315.4200 52.5700
Subtotal (Total Children Is Unduplicated) 207 654.000000 43671.0500 66.7753
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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 54 236.250000 11812.5000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 122 893.000000 44650.0000 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) 268 2766.503665 176858.3307 63.9285
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Total 3426.503665 220751.3807 64.4247
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Number of Children (Unduplicated) With at Least One Service 372
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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 16 17.250000 1142.7700 0.0000
H 0 0.000000 0.0000 0.0000
T 345 350.454800 17945.1200 17945.1200
2130 2322.818865 150227.4807 0.0000
Other 617 645.000000 43678.9300 0.0000
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Total 3191 3420.503665 220301.3807 19714.7100