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: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-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 3 5.500000 412.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 2 4.000000 300.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 0.500000 37.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 4 8.000000 444.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 85 181.500000 12612.5000 69.4904
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 3 6.000000 450.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 45 94.000000 6750.0000 71.8085
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 24.000000 1630.0000 67.9167
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 2 4.000000 300.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 82 164.000000 9102.0000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 2 4.000000 222.0000 55.5000
OCTH-97166-OT EVAL MODERATE COMPLEXITY 1 1.000000 51.4100 51.4100
PSTH-97162GT-PT EVAL MODERATE COMPLEXITY 1 1.000000 51.4100 51.4100
SCREEN-T1023-SCREENING 7 8.000000 354.0000 44.2500
SPCH-92521-EVAL OF SPEECH FLUENCY 1 1.000000 51.4100 51.4100
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 10 10.000000 514.1000 51.4100
SPL-92526-TREATMENT OF SWALLOWING DYSFUNCTION 8 24.000000 1151.5300 47.9804
Subtotal (Total Children Is Unduplicated) 126 544.500000 34734.3600 63.7913
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 1 0.750000 0.0000 0.0000
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 3 2.500000 125.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 163 734.500000 36525.0000 49.7277
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 2 1.750000 87.5000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 1 1.000000 10.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 15 65.000000 4461.5200 68.6388
OCCT-97530GT-OT SESSION BY LICENSED OT 2 2.000000 143.9200 71.9600
OCCT-97530HM-OT SESSION BY OT ASST 8 48.000000 2764.8000 57.6000
PHY-97110-PT SESSION BY LICENSED PT 27 79.750000 5738.7200 71.9589
PHY-97110GT-PT SESSION BY LICENSED PT 2 2.000000 143.9200 71.9600
PHY-97110HM-PT SESSION BY PT ASST 14 60.000000 3453.6000 57.5600
PHY-97110HMGT-PT SESSION BY LICENSED PT ASST 4 6.000000 345.3600 57.5600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 74 371.000000 25589.7200 68.9750
Subtotal (Total Children Is Unduplicated) 256 1374.250000 79389.0600 57.7690
-----------------------------------------------------------------------------------------------------------------------
Total 1918.750000 114123.4200 59.4780
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 342
-----------------------------------------------------------------------------------------------------------------------
Center 52
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 65 104.000000 6208.1900 4306.6800
D 211 231.000000 12387.4600 0.0000
S 0 0.000000 0.0000 0.0000
H 136 178.750000 11769.2800 0.0000
T 472 656.750000 38702.3900 33661.6300
495 748.250000 45056.1000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1379 1918.750000 114123.4200 37968.3100