CMS/EIP Fiscal Report Center: 06
Services beginning 01/01/2023 ending 03/31/2023 Date of Report:04/20/2023 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
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 1 0.500000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 1 1.000000 37.2000 37.2000
Subtotal (Total Children Is Unduplicated) 2 1.500000 37.2000 24.8000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 2.000000 150.0000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 4 6.500000 487.5000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 4 6.500000 487.5000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 2.000000 111.0000 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 3 6.000000 333.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 4 7.500000 562.5000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 79 133.000000 9975.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 3 5.500000 412.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 82 143.500000 10762.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 2 3.500000 262.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 37 66.000000 4950.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 4 7.500000 416.2500 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 118 211.500000 11738.2500 55.5000
Subtotal (Total Children Is Unduplicated) 172 603.000000 40798.5000 67.6592
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1 2.000000 100.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 20 78.500000 5172.5100 65.8918
OCCT-97530GT-OT SESSION BY LICENSED OT 4 7.750000 517.6900 66.7987
OCCT-97530HM-OT SESSION BY OT ASST 14 55.250000 3325.1400 60.1835
OCCT-97530HMGT-OT SESSION BY OT ASST 3 5.000000 287.1000 57.4200
PHY-97110-PT SESSION BY LICENSED PT 20 69.750000 4734.5600 67.8790
PHY-97110GT-PT SESSION BY LICENSED PT 9 24.000000 1680.2600 70.0108
PHY-97110HM-PT SESSION BY PT ASST 11 40.250000 2298.1400 57.0966
PHY-97110HMGT-PT SESSION BY LICENSED PT ASST 8 17.000000 989.3200 58.1953
SENS-V5264-EARMOLD 1 1.000000 18.1300 18.1300
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 52 218.750000 14946.3500 68.3262
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 26 89.000000 5419.1500 60.8893
Subtotal (Total Children Is Unduplicated) 134 608.250000 39488.3500 64.9212
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Total 1212.750000 80324.0500 66.2330
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Number of Children (Unduplicated) With at Least One Service 296
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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 328 243.750000 15313.9000 15313.9000
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
852 969.000000 65010.1500 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 1180 1212.750000 80324.0500 15313.9000