CMS/EIP Fiscal Report Center: 53
Services beginning 07/01/2022 ending 09/30/2022 Date of Report:10/18/2022 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
CASE-CASE-NON-TCM CASE MANAGEMENT 4 3.000000 111.6000 37.2000
TCM-T1017TL-TARGETED CASE MANAGEMENT 6 6.000000 222.0000 37.0000
Subtotal (Total Children Is Unduplicated) 7 9.000000 333.6000 37.0667
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Screening, Eval, and Assessment,Class #02
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 1 1.000000 19.5100 19.5100
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 2 2.000000 14.4000 7.2000
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 4 4.000000 115.6800 28.9200
AUDE-92582-CONDITIONED PLAY AUDIOMETRY 1 1.000000 44.7600 44.7600
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 13 21.000000 1575.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 4 5.500000 412.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 12 21.500000 1575.0000 73.2558
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 1 1.500000 112.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 11 18.000000 1350.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 2 3.000000 166.5000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 31 54.500000 3024.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 3 6.000000 450.0000 75.0000
SPL-92526-TREATMENT OF SWALLOWING DYSFUNCTION 1 2.000000 105.1400 52.5700
Subtotal (Total Children Is Unduplicated) 49 145.500000 9303.2400 63.9398
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 1 3.000000 214.3200 71.4400
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 2 0.750000 0.0000 0.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 40 152.000000 7600.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 23 47.000000 2350.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 13 43.250000 3126.5400 72.2899
OCCT-97530GT-OT SESSION BY LICENSED OT 5 6.000000 428.6400 71.4400
PHY-97110-PT SESSION BY LICENSED PT 16 110.500000 7902.4400 71.5153
PHY-97110GT-PT SESSION BY LICENSED PT 7 9.750000 696.5400 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 34 129.000000 9227.0700 71.5277
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 17 43.750000 3129.1400 71.5232
Subtotal (Total Children Is Unduplicated) 114 545.000000 34674.6900 63.6233
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Total 699.500000 44311.5300 63.3474
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Number of Children (Unduplicated) With at Least One Service 149
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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 12 4.500000 167.1000 0.0000
S 9 13.250000 886.2100 0.0000
H 4 3.250000 232.1800 0.0000
T 14 14.000000 700.0000 700.0000
617 654.750000 41711.2100 0.0000
Other 11 9.750000 614.8300 0.0000
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Total 667 699.500000 44311.5300 700.0000