CMS/EIP Fiscal Report Center: 09
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
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 8 27.250000 1012.9000 37.1706
Subtotal (Total Children Is Unduplicated) 8 27.250000 1012.9000 37.1706
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Screening, Eval, and Assessment,Class #02
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 1 2.000000 150.0000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 5 9.000000 675.0000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 1 2.000000 150.0000 75.0000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 7 15.000000 783.3600 52.2240
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 72 136.500000 10187.5000 74.6337
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 37 68.500000 5042.5000 73.6131
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 41 76.000000 5700.0000 75.0000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 87 165.000000 9032.5000 54.7424
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 20 41.500000 3112.5000 75.0000
OCTH-97165-OT EVAL LOW COMPLEXITY 1 1.000000 51.4100 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
SPCH-92521-EVAL OF SPEECH FLUENCY 3 3.000000 154.2300 51.4100
SPCH-92523GT-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 1 1.000000 51.4100 51.4100
Subtotal (Total Children Is Unduplicated) 159 524.000000 35305.7300 67.3773
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 5 23.000000 1150.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 36 232.000000 16585.9700 71.4913
OCCT-97530GT-OT SESSION BY LICENSED OT 3 11.500000 827.5400 71.9600
PHY-97110-PT SESSION BY LICENSED PT 50 306.500000 21498.3900 70.1416
PHY-97110GT-PT SESSION BY LICENSED PT 1 9.000000 378.0400 42.0044
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 128 906.000000 61777.0700 68.1866
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 9 47.000000 3346.1200 71.1940
Subtotal (Total Children Is Unduplicated) 202 1535.000000 105563.1300 68.7708
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Total 2086.250000 141881.7600 68.0080
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Number of Children (Unduplicated) With at Least One Service 350
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Center 09
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 379 1088.250000 76294.5100 76685.5500
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 163 481.500000 30317.5900 30317.5900
205 432.000000 29010.1600 0.0000
Other 44 84.500000 6259.5000 0.0000
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Total 791 2086.250000 141881.7600 107003.1400