CMS/EIP Fiscal Report Center: 57
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
Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 6 11.500000 862.5000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 7 13.500000 749.2500 55.5000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 82 148.500000 10810.6900 72.7993
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 21 34.500000 2542.6500 73.7000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 26 40.500000 3037.5000 75.0000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 116 208.500000 11421.7500 54.7806
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 13 22.000000 1650.0000 75.0000
OCTF-97168-OT RE-EVAL EST PLAN CARE 5 5.000000 257.0500 51.4100
OCTH-97166-OT EVAL MODERATE COMPLEXITY 1 1.000000 51.4100 51.4100
OCTH-97167-OT EVAL HIGH COMPLEXITY 3 3.000000 154.2300 51.4100
SPCH-92521-EVAL OF SPEECH FLUENCY 24 23.167089 1191.0200 51.4100
SPCH-92521GT-EVAL OF SPEECH FLUENCY 1 1.000000 51.4100 51.4100
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 9 10.000000 514.1000 51.4100
SPL-92526-TREATMENT OF SWALLOWING DYSFUNCTION 1 3.000000 158.7900 52.9300
Subtotal (Total Children Is Unduplicated) 178 527.167089 33602.3500 63.7414
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1 5.000000 250.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 36 203.195528 14621.9500 71.9600
OCCT-97530HM-OT SESSION BY OT ASST 5 39.000000 2246.4000 57.6000
PHY-97110-PT SESSION BY LICENSED PT 5 12.386882 891.3600 71.9600
PHY-97110GT-PT SESSION BY LICENSED PT 1 3.000000 215.8800 71.9600
PHY-97110HM-PT SESSION BY PT ASST 2 16.000000 920.9600 57.5600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 59 343.262091 24701.1400 71.9600
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 2 5.000000 359.8000 71.9600
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 1 3.000000 172.8000 57.6000
Subtotal (Total Children Is Unduplicated) 105 629.844501 44380.2900 70.4623
-----------------------------------------------------------------------------------------------------------------------
Total 1157.011590 77982.6400 67.4001
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 258
-----------------------------------------------------------------------------------------------------------------------
Center 57
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 25 28.413243 1949.8300 2329.5400
D 3 5.500000 373.5000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 95 246.598347 17114.8100 17114.8100
419 876.500000 58544.5000 28235.1600
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 542 1157.011590 77982.6400 47679.5100