CMS/EIP Fiscal Report Center: 09
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 1 0.250000 9.3000 37.2000
TCM-T1017TL-TARGETED CASE MANAGEMENT 14 36.500000 1357.8000 37.2000
Subtotal (Total Children Is Unduplicated) 14 36.750000 1367.1000 37.2000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 2 3.500000 223.5000 63.8571
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 3 5.500000 412.5000 75.0000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 3 6.000000 333.0000 55.5000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 54 86.500000 6450.0000 74.5665
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 29 50.500000 3787.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 21 37.000000 2775.0000 75.0000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 59 96.000000 5319.7500 55.4141
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 2 3.500000 262.5000 75.0000
OCTH-97165-OT EVAL LOW COMPLEXITY 3 3.000000 154.2300 51.4100
OCTH-97166GT-OT EVAL MODERATE COMPLEXITY 2 2.000000 102.8200 51.4100
SPCH-92521-EVAL OF SPEECH FLUENCY 1 1.000000 51.4100 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 16 76.000000 3907.1600 51.4100
Subtotal (Total Children Is Unduplicated) 134 371.500000 23830.7800 64.1475
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 19 58.000000 2900.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 77 357.000000 25545.8000 71.5569
OCCT-97530GT-OT SESSION BY LICENSED OT 1 3.000000 215.8800 71.9600
PHY-97110-PT SESSION BY LICENSED PT 107 705.000000 50333.0400 71.3944
PHY-97110GT-PT SESSION BY LICENSED PT 2 8.000000 575.6800 71.9600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 160 1076.000000 76796.0400 71.3718
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 16 77.000000 5540.9200 71.9600
Subtotal (Total Children Is Unduplicated) 298 2284.000000 161907.3600 70.8876
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Total 2692.250000 187105.2400 69.4977
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Number of Children (Unduplicated) With at Least One Service 415
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Center 09
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 610 1990.500000 138358.9400 138346.9800
D 7 22.000000 1511.1600 0.0000
S 0 0.000000 0.0000 0.0000
H 119 186.500000 12594.6800 12594.6800
T 0 0.000000 0.0000 0.0000
178 474.250000 33488.4600 0.0000
Other 11 19.000000 1152.0000 0.0000
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Total 925 2692.250000 187105.2400 150941.6600