CMS/EIP Fiscal Report Center: 52
Services beginning 07/01/2022 ending 06/30/2023 Date of Report:07/25/2023 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 8.250000 306.9000 37.2000
Subtotal (Total Children Is Unduplicated) 3 8.250000 306.9000 37.2000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 20 47.000000 2910.5200 61.9260
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 15 30.000000 2250.0000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 3 8.000000 450.0000 56.2500
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 3 4.500000 337.5000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 2.000000 150.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 21 42.000000 2331.0000 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 1 2.000000 111.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 375 821.250000 55800.5500 67.9459
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 7 14.000000 1050.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 189 386.000000 28250.0000 73.1865
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 19 38.000000 2850.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 76 160.000000 11350.0000 70.9375
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 8 20.000000 1160.0000 58.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 377 760.000000 41714.0000 54.8868
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 13 26.000000 1443.0000 55.5000
OCTH-97165GT-OT EVAL LOW COMPLEXITY 1 1.000000 51.4100 51.4100
OCTH-97166-OT EVAL MODERATE COMPLEXITY 2 3.000000 154.2300 51.4100
OCTH-97166GT-OT EVAL MODERATE COMPLEXITY 1 1.000000 51.4100 51.4100
PSTH-97161-PT EVAL LOW COMPLEXITY 1 1.000000 51.4100 51.4100
PSTH-97162GT-PT EVAL MODERATE COMPLEXITY 1 1.000000 51.4100 51.4100
PSTH-97163-PT EVAL HIGH COMPLEXITY 4 4.000000 205.2800 51.3200
SCREEN-T1023-SCREENING 67 74.000000 3404.0000 46.0000
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 28 32.000000 1531.6900 47.8653
SPCH-92523GT-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 1 1.000000 51.4100 51.4100
SPL-92526-TREATMENT OF SWALLOWING DYSFUNCTION 18 114.250000 4834.2525 42.3129
Subtotal (Total Children Is Unduplicated) 525 2595.000000 162694.0725 62.6952
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EI Services,Class #03
CONOF-CONOF-CONSULT, OT, FACE TO FACE 1 0.250000 12.5000 50.0000
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 4 3.250000 0.0000 0.0000
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 8 9.500000 475.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 335 3686.000000 179118.7500 48.5943
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 4 4.750000 237.5000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 3 4.000000 40.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 31 301.750000 20762.1500 68.8058
OCCT-97530GT-OT SESSION BY LICENSED OT 3 4.000000 287.8400 71.9600
OCCT-97530HM-OT SESSION BY OT ASST 16 186.000000 10292.1200 55.3340
PHY-97110-PT SESSION BY LICENSED PT 51 449.500000 32149.3100 71.5224
PHY-97110GT-PT SESSION BY LICENSED PT 2 2.000000 143.9200 71.9600
PHY-97110HM-PT SESSION BY PT ASST 21 352.500000 20006.5600 56.7562
PHY-97110HMGT-PT SESSION BY LICENSED PT ASST 9 20.250000 1156.3100 57.1017
PHY-97110TL-PT SESSION BY LICENSED PT 1 1.500000 107.9400 71.9600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 153 1816.130000 118087.6400 65.0216
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 4 3.000000 196.3300 65.4433
Subtotal (Total Children Is Unduplicated) 505 6844.380000 383073.8700 55.9691
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Total 9447.630000 546074.8425 57.8002
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Number of Children (Unduplicated) With at Least One Service 711
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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 443 636.000000 35171.7000 25325.1000
D 1016 1167.500000 63295.3800 535.3000
S 3 6.000000 450.0000 410.0000
H 430 584.500000 38775.7900 0.0000
T 3672 5329.630000 304056.9000 269224.8900
1059 1724.000000 104325.0725 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 6623 9447.630000 546074.8425 295495.2900