CMS/EIP Fiscal Report Center: 05
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-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 1 1.500000 83.2500 55.5000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
Subtotal (Total Children Is Unduplicated) 2 3.500000 233.2500 66.6429
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EI Services,Class #03
OCCT-97530-OT SESSION BY LICENSED OT 2 5.000000 359.8000 71.9600
PHY-97110-PT SESSION BY LICENSED PT 13 34.000000 1814.4600 53.3665
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 9 27.000000 1942.9200 71.9600
Subtotal (Total Children Is Unduplicated) 22 66.000000 4117.1800 62.3815
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Total 69.500000 4350.4300 62.5961
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Number of Children (Unduplicated) With at Least One Service 24
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Center 05
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 65 62.500000 3846.7100 3846.7100
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
7 7.000000 503.7200 503.7200
Other 0 0.000000 0.0000 0.0000
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Total 72 69.500000 4350.4300 4350.4300