CMS/EIP Fiscal Report Center: 57
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 4 7.000000 525.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 4 5.500000 305.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 64 100.000000 7500.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 1 1.500000 112.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 2 4.000000 300.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 41 60.500000 4537.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 102 166.000000 9213.0000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 2 3.500000 194.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 5 8.500000 637.5000 75.0000
OCTF-97168-OT RE-EVAL EST PLAN CARE 6 6.000000 308.4600 51.4100
OCTH-97167-OT EVAL HIGH COMPLEXITY 2 2.000000 102.8200 51.4100
SPCH-92521-EVAL OF SPEECH FLUENCY 3 3.000000 154.2300 51.4100
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 3 3.000000 174.7800 58.2600
SPCH-92523GT-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 1 1.000000 51.4100 51.4100
Subtotal (Total Children Is Unduplicated) 126 371.500000 24116.7000 64.9171
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1 8.000000 400.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 22 104.000000 7483.8400 71.9600
OCCT-97530HM-OT SESSION BY OT ASST 6 33.000000 1900.8000 57.6000
PHY-97110HM-PT SESSION BY PT ASST 1 4.000000 230.2400 57.5600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 15 97.000000 6980.1200 71.9600
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 3 7.000000 503.7200 71.9600
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 9 54.750000 3153.6000 57.6000
SPL-92507HMGT-SPL THERAPY SESSION BY SLP ASST 1 4.000000 230.4000 57.6000
Subtotal (Total Children Is Unduplicated) 53 311.750000 20882.7200 66.9855
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Total 683.250000 44999.4200 65.8608
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Number of Children (Unduplicated) With at Least One Service 165
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Center 57
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 12 9.604924 681.7400 125.0000
D 14 14.540857 960.2000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 48 58.000000 3859.7400 3859.7400
446 601.104219 39497.7400 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 520 683.250000 44999.4200 3984.7400