CMS/EIP Fiscal Report Center: 52
Services beginning 10/01/2023 ending 12/31/2023 Date of Report:01/14/2024 Page: 1
List order: No List
Agency Filter:EIP DEI DEIP
Payclass Filters:TPIN
Eligibility Filter:Part C (excluding not eligible)
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 1 1.500000 55.8000 37.2000
Subtotal (Total Children Is Unduplicated) 1 1.500000 55.8000 37.2000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 2 4.000000 300.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 2 4.000000 300.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 2.000000 111.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 33 71.500000 4848.1000 67.8056
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 8 16.000000 1200.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 21 43.000000 3021.2000 70.2605
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 11 23.500000 1597.5200 67.9796
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 23 45.500000 2525.2500 55.5000
OCTH-97167-OT EVAL HIGH COMPLEXITY 1 1.000000 51.4100 51.4100
SCREEN-T1023-SCREENING 3 3.000000 150.0000 50.0000
SPL-92526-TREATMENT OF SWALLOWING DYSFUNCTION 7 22.000000 1131.0200 51.4100
Subtotal (Total Children Is Unduplicated) 71 243.500000 15835.5000 65.0329
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EI Services,Class #03
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 1 0.250000 0.0000 0.0000
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 3 3.000000 150.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 102 392.500000 19625.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 14 65.000000 3250.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 1 1.000000 12.0000 12.0000
OCCT-97530-OT SESSION BY LICENSED OT 1 9.000000 647.6400 71.9600
OCCT-97530HM-OT SESSION BY OT ASST 3 5.000000 288.0000 57.6000
PHY-97110-PT SESSION BY LICENSED PT 28 115.000000 8275.4000 71.9600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 32 151.500000 10597.9800 69.9537
Subtotal (Total Children Is Unduplicated) 157 742.250000 42846.0200 57.7245
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Total 987.250000 58737.3200 59.4959
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Number of Children (Unduplicated) With at Least One Service 206
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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 77 83.500000 5537.1400 4425.4000
D 76 74.750000 5450.4500 0.0000
S 0 0.000000 0.0000 0.0000
H 89 110.250000 7993.7000 0.0000
T 437 461.750000 25664.8600 18641.8500
233 257.000000 14091.1700 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 912 987.250000 58737.3200 23067.2500