CMS/EIP Fiscal Report Center: 53
Services beginning 07/01/2023 ending 09/30/2023 Date of Report:10/10/2023 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
TCM-T1017TL-TARGETED CASE MANAGEMENT 3 4.500000 167.4000 37.2000
Subtotal (Total Children Is Unduplicated) 3 4.500000 167.4000 37.2000
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 1 1.000000 14.6800 14.6800
IPDEF-T1024GOTSGT-F/U PHYC 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-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 1 2.000000 111.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 1 1.500000 112.5000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 10 19.500000 1462.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 2 4.000000 300.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 19 34.000000 2550.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 8 14.500000 1087.5000 75.0000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 37 66.000000 3663.0000 55.5000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 2 4.000000 300.0000 75.0000
SPL-92526-TREATMENT OF SWALLOWING DYSFUNCTION 1 4.000000 211.7200 52.9300
Subtotal (Total Children Is Unduplicated) 61 156.500000 10262.9000 65.5776
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 2 2.000000 100.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 52 188.500000 9425.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 24 47.000000 2350.0000 50.0000
EPIC-99601-Early Steps Professional Development Fee 7 12.000000 180.0000 15.0000
OCCT-97530-OT SESSION BY LICENSED OT 24 105.000000 7555.8000 71.9600
OCCT-97530GT-OT SESSION BY LICENSED OT 7 11.000000 791.5600 71.9600
OCCT-97530TL-OT SESSION BY LICENSED OT 1 2.000000 143.9200 71.9600
OCCT-97530TLGT-OT SESSION BY LICENSED OT 1 1.000000 71.9600 71.9600
PHY-97110-PT SESSION BY LICENSED PT 21 80.750000 5774.7900 71.5144
PHY-97110GT-PT SESSION BY LICENSED PT 5 4.250000 305.8300 71.9600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 41 132.000000 9498.7200 71.9600
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 14 27.500000 1978.9000 71.9600
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 3 3.000000 215.8800 71.9600
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 1 0.500000 35.9800 71.9600
Subtotal (Total Children Is Unduplicated) 143 616.500000 38428.3400 62.3331
-----------------------------------------------------------------------------------------------------------------------
Total 777.500000 48858.6400 62.8407
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 191
-----------------------------------------------------------------------------------------------------------------------
Center 53
Flag Claims Units Chgs Paid
---------------------------------------------------------
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 71.9600
D 87 108.750000 6579.4800 0.0000
S 1 2.000000 150.0000 0.0000
H 134 137.000000 9852.6000 0.0000
T 127 130.000000 6169.3900 6058.3900
369 396.750000 25891.2900 0.0000
Other 2 2.000000 143.9200 0.0000
---------------------------------------------------------
Total 721 777.500000 48858.6400 6130.3500