CMS/EIP Fiscal Report Center: 01
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:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Screening, Eval, and Assessment,Class #02
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 1.500000 112.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 3 9.500000 712.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 2 3.000000 166.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 6 10.000000 750.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 5 8.000000 600.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 4 7.000000 525.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 1 1.500000 112.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 5 7.500000 562.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 18 26.500000 1470.7500 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 29 46.500000 2580.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 26 54.000000 4050.0000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 31 52.500000 3937.5000 75.0000
PSTH-97161-PT EVAL LOW COMPLEXITY 1 1.000000 51.4100 51.4100
PSTH-97162-PT EVAL MODERATE COMPLEXITY 1 1.000000 51.4100 51.4100
SPCH-92521-EVAL OF SPEECH FLUENCY 4 4.000000 205.6400 51.4100
SPCH-92523GT-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 1 1.000000 51.4100 51.4100
SPL-92526-TREATMENT OF SWALLOWING DYSFUNCTION 2 6.000000 317.5800 52.9300
Subtotal (Total Children Is Unduplicated) 90 242.500000 16407.9500 67.6616
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EI Services,Class #03
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 7 6.250000 312.5000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 326 1171.750000 58587.5000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 17 37.500000 1875.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 23 68.000000 4893.2800 71.9600
OCCT-97530GT-OT SESSION BY LICENSED OT 5 8.250000 593.6700 71.9600
PHY-97110-PT SESSION BY LICENSED PT 29 111.750000 8041.5300 71.9600
PHY-97110GT-PT SESSION BY LICENSED PT 4 4.000000 287.8400 71.9600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 69 273.500000 19681.0600 71.9600
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 15 61.250000 4407.5500 71.9600
Subtotal (Total Children Is Unduplicated) 401 1742.250000 98679.9300 56.6394
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Total 1984.750000 115087.8800 57.9861
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Number of Children (Unduplicated) With at Least One Service 473
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Center 01
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 698 707.000000 41670.1900 41670.1900
D 36 39.000000 2297.6400 0.0000
S 0 0.000000 0.0000 0.0000
H 165 198.000000 13446.7700 0.0000
T 919 927.500000 49956.6500 49823.0700
77 91.750000 6191.8800 0.0000
Other 13 21.500000 1524.7500 0.0000
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Total 1908 1984.750000 115087.8800 91493.2600