CMS/EIP Fiscal Report Center: 55
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
Screening, Eval, and Assessment,Class #02
EVAL-96111-DEVELOPMENTAL EVALUATION 3 5.000000 250.0000 50.0000
EVAL-96111GT-DEVELOPMENTAL EVALUATION 1 1.000000 50.0000 50.0000
EXIT-EXIT-EXIT ASSESSMENT 1 2.000000 100.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 2 4.000000 300.0000 75.0000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 84 154.984265 11623.8200 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 7 12.229866 917.2400 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 4 8.000000 600.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 9 14.384534 1078.8400 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 2 4.000000 300.0000 75.0000
OCTF-97168-OT RE-EVAL EST PLAN CARE 4 4.000000 205.6400 51.4100
OCTH-97166-OT EVAL MODERATE COMPLEXITY 2 2.141412 110.0900 51.4100
OCTH-97167-OT EVAL HIGH COMPLEXITY 10 10.000000 514.1000 51.4100
OCTH-97167GT-OT EVAL HIGH COMPLEXITY 1 1.000000 51.4100 51.4100
PSTF-97164-PT RE-EVAL EST PLAN CARE 1 0.194515 10.0000 51.4099
PSTH-97163-PT EVAL HIGH COMPLEXITY 1 1.000000 51.4100 51.4100
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 5 5.760357 296.1400 51.4100
Subtotal (Total Children Is Unduplicated) 120 229.694949 16458.6900 71.6546
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 3 6.000000 300.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 1 3.000000 30.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 23 107.831156 7759.5300 71.9600
OCCT-97530GT-OT SESSION BY LICENSED OT 1 2.000000 143.9200 71.9600
OCCT-97530HM-OT SESSION BY OT ASST 32 327.409722 18858.8000 57.6000
PHY-97110-PT SESSION BY LICENSED PT 21 177.611726 12780.9400 71.9600
PHY-97110GT-PT SESSION BY LICENSED PT 1 1.000000 71.9600 71.9600
PHY-97110HM-PT SESSION BY PT ASST 10 58.328005 3357.3600 57.5600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 38 228.208449 16421.8800 71.9600
Subtotal (Total Children Is Unduplicated) 106 911.389058 59724.3900 65.5312
-----------------------------------------------------------------------------------------------------------------------
Total 1141.084007 76183.0800 66.7638
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 197
-----------------------------------------------------------------------------------------------------------------------
Center 55
Flag Claims Units Chgs Paid
---------------------------------------------------------
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 262 263.750000 17701.6000 17701.6000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 91 154.500000 11392.4700 0.0000
T 0 0.000000 0.0000 0.0000
728 722.834007 47089.0100 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1081 1141.084007 76183.0800 17701.6000