CMS/EIP Fiscal Report Center: 06
Services beginning 10/01/2022 ending 12/31/2022 Date of Report:01/23/2023 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-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 2 4.000000 300.0000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 1 1.500000 112.5000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 2 3.500000 262.5000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 2 4.000000 300.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 2 4.000000 222.0000 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 2 3.500000 194.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 3 6.000000 450.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 69 117.000000 8690.0000 74.2735
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 4 7.500000 562.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 71 119.500000 8962.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 48 85.500000 6412.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 5 10.000000 555.0000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 118 208.000000 11573.2500 55.6406
MED-99205-OUTPATIENT VISIT, NEW, 60 MINS 1 1.000000 50.0000 50.0000
Subtotal (Total Children Is Unduplicated) 166 575.000000 38647.0000 67.2122
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 2 3.000000 150.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 15 73.250000 4920.9000 67.1795
OCCT-97530GT-OT SESSION BY LICENSED OT 1 0.500000 28.8000 57.6000
OCCT-97530HM-OT SESSION BY OT ASST 10 64.000000 2691.1300 42.0489
OCCT-97530HMGT-OT SESSION BY OT ASST 2 6.500000 374.4000 57.6000
PHY-97110-PT SESSION BY LICENSED PT 16 70.250000 4406.8000 62.7302
PHY-97110GT-PT SESSION BY LICENSED PT 6 9.750000 676.0300 69.3364
PHY-97110HM-PT SESSION BY PT ASST 14 61.250000 3442.4000 56.2024
PHY-97110HMGT-PT SESSION BY LICENSED PT ASST 7 16.250000 877.1900 53.9809
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 40 195.250000 12890.9200 66.0226
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 29 103.500000 6864.5400 66.3241
Subtotal (Total Children Is Unduplicated) 126 603.500000 37323.1100 61.8444
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Total 1178.500000 75970.1100 64.4634
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Number of Children (Unduplicated) With at Least One Service 278
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Center 06
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 223 152.250000 9233.9600 9233.9600
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
956 1026.250000 66736.1500 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 1179 1178.500000 75970.1100 9233.9600