CMS/EIP Fiscal Report Center: 57
Services beginning 10/01/2022 ending 12/31/2022 Date of Report:01/23/2023 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
Screening, Eval, and Assessment,Class #02
AUDE-92550-TYMPANOMETRY & REFLEX THRESH 1 1.000000 13.8000 13.8000
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 1 1.000000 19.5100 19.5100
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 1 1.000000 14.6800 14.6800
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 1 1.000000 28.9200 28.9200
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 1 1.000000 21.0400 21.0400
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 2 3.000000 225.0000 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 3 6.000000 333.0000 55.5000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 46 86.500000 6487.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 10 19.000000 1425.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 12 21.500000 1612.5000 75.0000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 61 116.000000 6438.0000 55.5000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 5 9.500000 712.5000 75.0000
OCTF-97168-OT RE-EVAL EST PLAN CARE 1 1.000000 51.4100 51.4100
OCTH-97167-OT EVAL HIGH COMPLEXITY 9 9.000000 462.6900 51.4100
PSTF-97164GT-PT RE-EVAL EST PLAN CARE 1 1.000000 51.4100 51.4100
SPCH-92521-EVAL OF SPEECH FLUENCY 12 12.000000 616.9200 51.4100
SPL-92526-TREATMENT OF SWALLOWING DYSFUNCTION 1 6.000000 342.5600 57.0933
Subtotal (Total Children Is Unduplicated) 89 297.500000 19006.4400 63.8872
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 5 32.000000 1600.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 27 146.494171 10541.7200 71.9600
OCCT-97530HM-OT SESSION BY OT ASST 1 3.000000 172.8000 57.6000
PHY-97110-PT SESSION BY LICENSED PT 5 25.000002 1799.0000 71.9600
PHY-97110GT-PT SESSION BY LICENSED PT 1 0.500000 35.9800 71.9600
PHY-97110HM-PT SESSION BY PT ASST 1 1.000000 57.5600 57.5600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 55 315.500445 22703.3800 71.9599
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 1 3.500000 251.8600 71.9600
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 4 11.500000 662.4000 57.6000
SPL-92507HMGT-SPL THERAPY SESSION BY SLP ASST 1 2.000000 115.2000 57.6000
Subtotal (Total Children Is Unduplicated) 91 540.494618 37939.9000 70.1948
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Total 837.994618 56946.3400 67.9555
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Number of Children (Unduplicated) With at Least One Service 168
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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 35 46.537128 3312.9800 3584.8600
D 0 0.000000 0.0000 0.0000
S 5 11.500000 719.8000 719.8000
H 5 5.000000 97.9500 97.9500
T 103 262.957490 18698.5700 18698.5700
239 511.000000 34065.6300 16982.1300
Other 1 1.000000 51.4100 51.4100
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Total 388 837.994618 56946.3400 40134.7200