CMS/EIP Fiscal Report Center: 03
Services beginning 10/01/2023 ending 12/31/2023 Date of Report:01/14/2024 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 3.500000 262.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 32 54.500000 4046.1300 74.2409
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 4 5.000000 375.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 28 46.500000 3386.4400 72.8267
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 5 10.000000 571.9300 57.1930
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 14 25.000000 1387.5000 55.5000
PSTH-97162-PT EVAL MODERATE COMPLEXITY 1 1.000000 51.4100 51.4100
SPCH-92521-EVAL OF SPEECH FLUENCY 1 1.000000 51.4100 51.4100
SPL-92526-TREATMENT OF SWALLOWING DYSFUNCTION 1 2.000000 102.8200 51.4100
Subtotal (Total Children Is Unduplicated) 66 150.500000 10385.1400 69.0043
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 32 48.000000 2400.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 2 3.000000 150.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 4 5.750000 413.7700 71.9600
OCCT-97530GT-OT SESSION BY LICENSED OT 1 1.000000 71.9600 71.9600
PHY-97110-PT SESSION BY LICENSED PT 16 43.750000 2746.2300 62.7710
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 21 54.000000 3379.2200 62.5781
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 1 1.000000 71.9600 71.9600
Subtotal (Total Children Is Unduplicated) 74 156.500000 9233.1400 58.9977
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Total 307.000000 19618.2800 63.9032
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Number of Children (Unduplicated) With at Least One Service 135
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Center 03
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 18 19.500000 1200.3400 1200.3400
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 3 3.000000 150.0000 150.0000
T 0 0.000000 0.0000 0.0000
226 284.500000 18267.9400 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 247 307.000000 19618.2800 1350.3400