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
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 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 3 6.000000 450.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 2 4.000000 222.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 64 137.000000 9445.8000 68.9474
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 13 26.000000 1950.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 41 83.000000 6021.2000 72.5446
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 8 16.000000 1200.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 19 38.000000 2685.0200 70.6584
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 56 109.500000 6077.2500 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
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 2 2.000000 102.8200 51.4100
SPL-92526-TREATMENT OF SWALLOWING DYSFUNCTION 12 55.000000 2416.2700 43.9322
Subtotal (Total Children Is Unduplicated) 120 486.500000 31221.7700 64.1763
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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 187 777.500000 38875.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 15 66.000000 3300.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 1 1.000000 12.0000 12.0000
OCCT-97530-OT SESSION BY LICENSED OT 16 92.000000 6620.3200 71.9600
OCCT-97530HM-OT SESSION BY OT ASST 8 14.000000 748.8000 53.4857
PHY-97110-PT SESSION BY LICENSED PT 44 160.000000 11513.6000 71.9600
PHY-97110HM-PT SESSION BY PT ASST 14 49.000000 2762.8800 56.3853
PHY-97110HMGT-PT SESSION BY LICENSED PT ASST 3 4.000000 230.2400 57.5600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 81 354.250000 24828.0700 70.0863
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 1 0.500000 35.9800 71.9600
Subtotal (Total Children Is Unduplicated) 296 1521.500000 89076.8900 58.5454
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Total 2009.500000 120354.4600 59.8927
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Number of Children (Unduplicated) With at Least One Service 377
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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 82 92.500000 6177.3000 4987.5500
D 79 80.750000 5900.4500 0.0000
S 0 0.000000 0.0000 0.0000
H 97 125.750000 9156.2000 0.0000
T 1103 1178.750000 66729.0600 59513.6500
481 531.750000 32391.4500 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 1842 2009.500000 120354.4600 64501.2000