CMS/EIP Fiscal Report Center: 06
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
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 33 57.250000 2129.7000 37.2000
Subtotal (Total Children Is Unduplicated) 33 57.250000 2129.7000 37.2000
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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-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 2.000000 111.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 23 41.500000 3112.5000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 78 148.000000 11100.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 18 32.500000 2437.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 38 69.500000 5212.5000 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 10 19.000000 1425.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 19 35.500000 2009.2500 56.5986
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 73 139.500000 7781.2500 55.7796
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 1 1.000000 51.4100 51.4100
Subtotal (Total Children Is Unduplicated) 134 494.000000 33652.9100 68.1233
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EI Services,Class #03
COIFF-COIFFGT-IFSP CONSULT, PROF, TELEMEDICINE 1 1.000000 50.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 7 33.000000 1650.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 8 46.000000 3267.6500 71.0359
OCCT-97530GT-OT SESSION BY LICENSED OT 5 22.250000 1601.1100 71.9600
OCCT-97530HM-OT SESSION BY OT ASST 6 27.250000 1470.2000 53.9523
OCCT-97530HMGT-OT SESSION BY OT ASST 3 6.500000 374.4000 57.6000
PHY-97110-PT SESSION BY LICENSED PT 14 43.250000 2887.3100 66.7586
PHY-97110GT-PT SESSION BY LICENSED PT 3 6.250000 449.7500 71.9600
PHY-97110HM-PT SESSION BY PT ASST 8 33.750000 1942.6500 57.5600
PHY-97110HMGT-PT SESSION BY LICENSED PT ASST 2 6.000000 345.3600 57.5600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 42 210.000000 14553.8100 69.3039
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 10 27.250000 1784.0800 65.4708
Subtotal (Total Children Is Unduplicated) 97 462.500000 30376.3200 65.6785
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Total 1013.750000 66158.9300 65.2616
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Number of Children (Unduplicated) With at Least One Service 260
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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 283 237.250000 15126.3600 15126.3600
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
611 761.750000 50483.8700 0.0000
Other 24 14.750000 548.7000 0.0000
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Total 918 1013.750000 66158.9300 15126.3600