CMS/EIP Fiscal Report Center: 52
Services beginning 10/01/2022 ending 12/31/2022 Date of Report:01/23/2023 Page: 1
List order: No List
Payclass Filters:MED
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 422 1034.500000 38318.6000 37.0407
Subtotal (Total Children Is Unduplicated) 422 1034.500000 38318.6000 37.0407
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 4 8.000000 600.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 5 10.000000 555.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 81 160.000000 12000.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 32 64.000000 4800.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 2 4.000000 300.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 11 22.000000 1650.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 71 141.500000 7853.2500 55.5000
OCTH-97165TL-OT EVAL LOW COMPLEXITY 1 1.000000 51.4100 51.4100
OCTH-97166-OT EVAL MODERATE COMPLEXITY 1 1.000000 51.4100 51.4100
PSTH-97162TL-PT EVAL MODERATE COMPLEXITY 1 1.000000 51.4100 51.4100
SCREEN-T1023-SCREENING 17 17.000000 850.0000 50.0000
SPCH-92522TL-EVAL OF SPCH SOUND PROD 2 2.000000 102.8200 51.4100
SPCH-92523TL-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 8 8.000000 411.2800 51.4100
SPL-92526TL-TREATMENT OF SWALLOWING DYSFUNCTION 4 10.000000 529.3000 52.9300
Subtotal (Total Children Is Unduplicated) 127 451.500000 29955.8800 66.3475
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 234 1035.750000 51787.5000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 1 1.000000 50.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 14 39.000000 2806.4400 71.9600
OCCT-97530GT-OT SESSION BY LICENSED OT 1 0.750000 53.9700 71.9600
OCCT-97530TL-OT SESSION BY LICENSED OT 22 72.250000 5199.1100 71.9600
OCCT-97530TLGTHM-OT SESSION BY OT ASST 1 0.500000 28.8000 57.6000
OCCT-97530TLHM-OT SESSION BY OT ASST 10 56.000000 3225.6000 57.6000
PHY-97110HM-PT SESSION BY PT ASST 1 1.000000 57.5600 57.5600
PHY-97110HMGT-PT SESSION BY LICENSED PT ASST 1 1.000000 57.5600 57.5600
PHY-97110TL-PT SESSION BY LICENSED PT 27 73.750000 5307.0500 71.9600
PHY-97110TLGT-PT SESSION BY LICENSED PT 1 0.750000 53.9700 71.9600
PHY-97110TLGTHM-PT SESSION BY PT ASST 1 1.000000 57.5600 57.5600
PHY-97110TLHM-PT SESSION BY PT ASST 6 35.000000 2014.6000 57.5600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 4 6.000000 431.7600 71.9600
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 62 300.500000 21623.9800 71.9600
Subtotal (Total Children Is Unduplicated) 322 1624.250000 92755.4600 57.1066
-----------------------------------------------------------------------------------------------------------------------
Total 3110.250000 161029.9400 51.7740
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 531
-----------------------------------------------------------------------------------------------------------------------
Center 52
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 37 40.750000 2754.7200 0.0000
U 0 0.000000 0.0000 0.0000
B 1068 1071.000000 51655.2400 27.9000
P 820 847.750000 40293.4000 161156.9800
D 0 0.000000 0.0000 0.0000
S 117 89.250000 3357.5000 0.0000
H 0 0.000000 0.0000 0.0000
T 1 2.000000 143.9200 0.0000
645 1059.500000 62825.1600 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 2688 3110.250000 161029.9400 161184.8800