CMS/EIP Fiscal Report Center: 03
Services beginning 01/01/2023 ending 03/31/2023 Date of Report:04/20/2023 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 1 2.000000 150.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 1.500000 112.5000 75.0000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 2 4.000000 300.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 8 14.500000 991.4900 68.3786
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 5 9.000000 675.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 8 14.500000 804.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 5 7.000000 525.0000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 1.000000 75.0000 75.0000
OCTH-97165-OT EVAL LOW COMPLEXITY 1 1.000000 51.4100 51.4100
PSTF-97164-PT RE-EVAL EST PLAN CARE 1 1.000000 51.4100 51.4100
PSTH-97161-PT EVAL LOW COMPLEXITY 2 2.000000 102.8200 51.4100
SPCH-92521-EVAL OF SPEECH FLUENCY 8 8.000000 354.1400 44.2675
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 3 3.000000 154.2300 51.4100
Subtotal (Total Children Is Unduplicated) 45 70.500000 4497.7500 63.7979
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 1 1.000000 50.0000 50.0000
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 18 21.000000 1050.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 22 27.000000 1350.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 201 780.500000 39025.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 4 6.000000 431.7600 71.9600
PHY-97110-PT SESSION BY LICENSED PT 16 41.000000 2893.9300 70.5837
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 36 102.750000 6736.2400 65.5595
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 1 2.000000 143.9200 71.9600
Subtotal (Total Children Is Unduplicated) 261 981.250000 51680.8500 52.6684
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Total 1051.750000 56178.6000 53.4144
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Number of Children (Unduplicated) With at Least One Service 289
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Center 03
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 3 3.000000 193.9200 193.9200
D 0 0.000000 0.0000 0.0000
S 4 4.000000 200.0000 200.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
1015 1044.750000 55784.6800 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 1022 1051.750000 56178.6000 393.9200