CMS/EIP Fiscal Report Center: 53
Services beginning 01/01/2023 ending 03/31/2023 Date of Report:04/20/2023 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 1 0.500000 18.6000 37.2000
TCM-T1017TL-TARGETED CASE MANAGEMENT 5 3.750000 139.5000 37.2000
Subtotal (Total Children Is Unduplicated) 6 4.250000 158.1000 37.2000
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Screening, Eval, and Assessment,Class #02
AUDE-92550-TYMPANOMETRY & REFLEX THRESH 1 1.000000 13.8000 13.8000
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 1 1.000000 7.2000 7.2000
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 2 2.000000 57.8400 28.9200
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 2 3.500000 262.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 1.500000 112.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 2 3.000000 166.5000 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 1 1.500000 83.2500 55.5000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 15 27.500000 2062.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 2 3.500000 262.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 13 24.500000 1837.5000 75.0000
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 15 27.000000 2025.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 7 13.000000 721.5000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 31 56.000000 3108.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 2 4.000000 300.0000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 4 7.000000 462.5000 66.0714
Subtotal (Total Children Is Unduplicated) 57 177.500000 11595.5900 65.3273
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EI Services,Class #03
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 1 1.000000 0.0000 0.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 44 157.250000 7862.5000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 25 50.500000 2525.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 18 93.250000 6710.2700 71.9600
OCCT-97530GT-OT SESSION BY LICENSED OT 3 7.000000 503.7200 71.9600
PHY-97110-PT SESSION BY LICENSED PT 18 82.250000 5918.7100 71.9600
PHY-97110GT-PT SESSION BY LICENSED PT 5 11.000000 791.5600 71.9600
PHY-97110TL-PT SESSION BY LICENSED PT 1 6.000000 431.7600 71.9600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 41 157.750000 11351.6900 71.9600
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 18 24.750000 1781.0100 71.9600
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 2 5.000000 359.8000 71.9600
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 1 2.500000 179.9000 71.9600
Subtotal (Total Children Is Unduplicated) 129 598.250000 38415.9200 64.2138
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Total 780.000000 50169.6100 64.3200
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Number of Children (Unduplicated) With at Least One Service 171
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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 1 1.000000 71.9600 72.0000
D 27 23.250000 1572.9000 0.0000
S 1 1.500000 150.0000 0.0000
H 42 42.000000 2821.6300 0.0000
T 5 5.000000 186.1200 186.1200
637 705.250000 45267.0000 0.0000
Other 2 2.000000 100.0000 0.0000
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Total 715 780.000000 50169.6100 258.1200