CMS/EIP Fiscal Report Center: 07
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
CASE-CASE-NON-TCM CASE MANAGEMENT 5 1.500000 55.8000 37.2000
TCM-T1017TL-TARGETED CASE MANAGEMENT 10 12.250000 455.7000 37.2000
Subtotal (Total Children Is Unduplicated) 13 13.750000 511.5000 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-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 1 2.000000 150.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 2.000000 150.0000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 1 2.000000 150.0000 75.0000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 29 58.000000 4350.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 9 18.000000 1350.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 26 52.000000 3900.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 5 8.880000 666.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 21 41.099800 3082.4850 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 8 16.000000 1200.0000 75.0000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 15 28.468000 2135.1000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 3 6.000000 450.0000 75.0000
OCTF-97168-OT RE-EVAL EST PLAN CARE 3 3.000000 154.2300 51.4100
OCTH-97166-OT EVAL MODERATE COMPLEXITY 3 3.000000 154.2300 51.4100
PSTH-97161-PT EVAL LOW COMPLEXITY 1 1.000000 51.4100 51.4100
PSTH-97162-PT EVAL MODERATE COMPLEXITY 1 1.000000 51.4100 51.4100
PSTH-97162GT-PT EVAL MODERATE COMPLEXITY 1 1.000000 51.4100 51.4100
SPCH-92521-EVAL OF SPEECH FLUENCY 1 1.000000 51.4100 51.4100
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 18 18.000000 925.3800 51.4100
SPCH-92523GT-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 1 1.000000 51.4100 51.4100
SPL-92526-TREATMENT OF SWALLOWING DYSFUNCTION 3 11.000000 565.5100 51.4100
Subtotal (Total Children Is Unduplicated) 124 280.447800 20089.9850 71.6354
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 1 1.000000 1257.6000 1257.6000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 18 53.750000 2687.5000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 4 7.000000 350.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 46 169.500000 12197.2200 71.9600
PHY-97110-PT SESSION BY LICENSED PT 23 82.750000 5954.6900 71.9600
PHY-97110GT-PT SESSION BY LICENSED PT 4 8.500000 611.6600 71.9600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 73 339.000000 24394.4400 71.9600
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 2 9.000000 647.6400 71.9600
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 2 11.000000 633.6000 57.6000
SPL-92507HMGT-SPL THERAPY SESSION BY SLP ASST 3 19.250000 1108.8000 57.6000
Subtotal (Total Children Is Unduplicated) 145 700.750000 49843.1500 71.1283
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Total 994.947800 70444.6350 70.8023
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Number of Children (Unduplicated) With at Least One Service 254
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Center 07
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 766 769.197800 54033.1350 54033.1300
D 8 16.000000 1200.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 10 20.000000 1500.0000 0.0000
T 0 0.000000 0.0000 0.0000
105 189.750000 13711.5000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 889 994.947800 70444.6350 54033.1300