CMS/EIP Fiscal Report Center: 53
Services beginning 10/01/2023 ending 12/31/2023 Date of Report:01/14/2024 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 9 11.000000 409.2000 37.2000
Subtotal (Total Children Is Unduplicated) 9 11.000000 409.2000 37.2000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 2 3.500000 262.5000 75.0000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 1 2.000000 111.0000 55.5000
IPDEI-IPDEI_NM-INITIAL PSYCH & DEV EVAL BY NON-MED PR 1 2.000000 111.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 5 9.500000 712.5000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 11 18.500000 1387.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 8 14.000000 1087.5000 77.6786
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 19 31.500000 2362.5000 75.0000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 20 34.500000 1914.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 2.000000 150.0000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 2 4.000000 300.0000 75.0000
SPL-92526-TREATMENT OF SWALLOWING DYSFUNCTION 1 5.000000 257.0500 51.4100
Subtotal (Total Children Is Unduplicated) 55 128.000000 8768.8000 68.5063
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 1 1.000000 1960.0000 1960.0000
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 2 2.500000 0.0000 0.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 29 90.500000 4525.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 8 13.000000 637.2000 49.0154
OCCT-97530-OT SESSION BY LICENSED OT 28 132.000000 9498.7200 71.9600
OCCT-97530GT-OT SESSION BY LICENSED OT 11 23.500000 1691.0600 71.9600
PHY-97110-PT SESSION BY LICENSED PT 26 106.750000 7849.7700 73.5341
PHY-97110GT-PT SESSION BY LICENSED PT 5 4.250000 305.8300 71.9600
PHY-97110TL-PT SESSION BY LICENSED PT 1 1.000000 71.9600 71.9600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 31 141.350000 10171.6300 71.9606
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 9 12.270000 883.3300 71.9910
Subtotal (Total Children Is Unduplicated) 117 528.120000 37594.5000 71.1855
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Total 667.120000 46772.5000 70.1111
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Number of Children (Unduplicated) With at Least One Service 164
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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 11 6.680000 650.0800 485.6800
D 119 122.440000 7989.1200 0.0000
S 0 0.000000 0.0000 0.0000
H 92 95.000000 6806.4700 0.0000
T 54 55.500000 4726.2100 4726.2100
363 387.500000 26600.6200 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 639 667.120000 46772.5000 5211.8900