CMS/EIP Fiscal Report Center: 52
Services beginning 01/01/2023 ending 03/31/2023 Date of Report:04/20/2023 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
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 3 5.750000 213.9000 37.2000
Subtotal (Total Children Is Unduplicated) 3 5.750000 213.9000 37.2000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 8 15.500000 1162.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 3 6.000000 450.0000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 9 18.000000 999.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 86 186.500000 12967.5000 69.5308
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 1 2.000000 150.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 43 86.000000 6350.0000 73.8372
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 4 8.000000 600.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 9 20.000000 1340.0000 67.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 97 193.500000 10739.2500 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 2 4.000000 222.0000 55.5000
OCTH-97165GT-OT EVAL LOW COMPLEXITY 1 1.000000 51.4100 51.4100
OCTH-97166GT-OT EVAL MODERATE COMPLEXITY 1 1.000000 51.4100 51.4100
PSTH-97163-PT EVAL HIGH COMPLEXITY 1 1.000000 51.4100 51.4100
SCREEN-T1023-SCREENING 14 14.000000 700.0000 50.0000
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 1 1.000000 51.4100 51.4100
SPL-92526-TREATMENT OF SWALLOWING DYSFUNCTION 8 20.000000 516.3300 25.8165
Subtotal (Total Children Is Unduplicated) 150 579.500000 36552.2200 63.0754
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EI Services,Class #03
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 1 1.000000 0.0000 0.0000
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 2 2.000000 100.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 190 923.000000 45985.0000 49.8212
OCCT-97530-OT SESSION BY LICENSED OT 13 42.500000 3058.3000 71.9600
OCCT-97530GT-OT SESSION BY LICENSED OT 1 1.000000 71.9600 71.9600
OCCT-97530HM-OT SESSION BY OT ASST 9 28.000000 1612.8000 57.6000
PHY-97110-PT SESSION BY LICENSED PT 29 83.750000 6026.6500 71.9600
PHY-97110HM-PT SESSION BY PT ASST 12 88.750000 5050.8900 56.9114
PHY-97110HMGT-PT SESSION BY LICENSED PT ASST 3 2.000000 115.1200 57.5600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 72 352.250000 24113.2900 68.4550
Subtotal (Total Children Is Unduplicated) 275 1524.250000 86134.0100 56.5091
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Total 2109.500000 122900.1300 58.2603
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Number of Children (Unduplicated) With at Least One Service 371
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Center 52
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 65 93.000000 5112.2000 3659.5300
D 251 276.500000 15093.0000 165.0000
S 2 2.750000 203.9700 130.0000
H 240 299.000000 17836.3000 0.0000
T 670 908.500000 52759.4200 45343.1400
327 529.750000 31895.2400 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 1555 2109.500000 122900.1300 49297.6700