CMS/EIP Fiscal Report Center: 05
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:Part C (excluding not eligible)
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Screening, Eval, and Assessment,Class #02
PSTH-97161-PT EVAL LOW COMPLEXITY 1 1.000000 51.4100 51.4100
PSTH-97163-PT EVAL HIGH COMPLEXITY 1 1.000000 51.4100 51.4100
SPL-92526-TREATMENT OF SWALLOWING DYSFUNCTION 1 5.000000 264.6500 52.9300
Subtotal (Total Children Is Unduplicated) 3 7.000000 367.4700 52.4957
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EI Services,Class #03
OCCT-97530-OT SESSION BY LICENSED OT 2 2.000000 96.7500 48.3750
PHY-97110-PT SESSION BY LICENSED PT 7 24.500000 959.0800 39.1461
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 14 34.000000 1871.4200 55.0418
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 1 1.000000 42.1800 42.1800
Subtotal (Total Children Is Unduplicated) 24 61.500000 2969.4300 48.2834
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Total 68.500000 3336.9000 48.7139
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Number of Children (Unduplicated) With at Least One Service 25
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Center 05
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 43 66.500000 3240.1500 3240.1500
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
2 2.000000 96.7500 96.7500
Other 0 0.000000 0.0000 0.0000
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Total 45 68.500000 3336.9000 3336.9000