CMS/EIP Fiscal Report Center: 53
Services beginning 04/01/2023 ending 06/30/2023 Date of Report:07/25/2023 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 2 3.250000 120.9000 37.2000
TCM-T1017TL-TARGETED CASE MANAGEMENT 6 6.750000 251.1000 37.2000
Subtotal (Total Children Is Unduplicated) 8 10.000000 372.0000 37.2000
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Screening, Eval, and Assessment,Class #02
AUDE-92550-TYMPANOMETRY & REFLEX THRESH 3 3.000000 47.5200 15.8400
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 4 4.000000 115.6800 28.9200
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 2 2.000000 27.6200 13.8100
AUDE-92588-OTOACOUSTIC EMISSIONS (COMP) 1 1.000000 21.0400 21.0400
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 2.000000 150.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 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-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 2.000000 150.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 2.000000 111.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 5 8.000000 600.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 11 20.000000 1500.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 14 20.500000 1537.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 17 27.500000 2062.5000 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 36 62.000000 3441.0000 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 1 1.500000 112.5000 75.0000
SPL-92526TL-TREATMENT OF SWALLOWING DYSFUNCTION 1 7.000000 368.9900 52.7129
Subtotal (Total Children Is Unduplicated) 62 173.500000 11011.8500 63.4689
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 4 7.000000 9044.4200 1292.0600
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 1 1.250000 0.0000 0.0000
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 1 1.000000 50.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 63 242.750000 12037.5000 49.5881
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 31 64.500000 3225.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 21 116.000000 8347.3600 71.9600
OCCT-97530GT-OT SESSION BY LICENSED OT 3 4.000000 287.8400 71.9600
OCCT-97530TL-OT SESSION BY LICENSED OT 1 1.000000 71.9600 71.9600
PHY-97110-PT SESSION BY LICENSED PT 26 153.250000 11027.8700 71.9600
PHY-97110GT-PT SESSION BY LICENSED PT 5 5.000000 359.8000 71.9600
PHY-97110TL-PT SESSION BY LICENSED PT 1 2.000000 143.9200 71.9600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 37 196.000000 14456.3200 73.7567
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 16 22.750000 1637.0900 71.9600
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 1 3.000000 215.8800 71.9600
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 1 1.000000 71.9600 71.9600
Subtotal (Total Children Is Unduplicated) 152 820.500000 60976.9200 74.3168
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Total 1004.000000 72360.7700 72.0725
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Number of Children (Unduplicated) With at Least One Service 197
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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 4 4.000000 640.0000 448.0000
D 54 57.500000 3028.2600 0.0000
S 4 4.000000 200.0000 0.0000
H 43 43.500000 3136.3400 0.0000
T 118 122.000000 14604.8000 14604.8000
723 772.000000 50679.4100 0.0000
Other 1 1.000000 71.9600 0.0000
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Total 947 1004.000000 72360.7700 15052.8000