CMS/EIP Fiscal Report Center: 02
Services beginning 04/01/2023 ending 06/30/2023 Date of Report:07/25/2023 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 1.500000 112.5000 75.0000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 2 4.000000 300.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 1 2.000000 150.0000 75.0000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 2.000000 150.0000 75.0000
OCTF-97168-OT RE-EVAL EST PLAN CARE 1 1.000000 37.1500 37.1500
OCTH-97165-OT EVAL LOW COMPLEXITY 1 1.000000 51.4100 51.4100
OCTH-97166GT-OT EVAL MODERATE COMPLEXITY 3 3.000000 154.2300 51.4100
PSTF-97164-PT RE-EVAL EST PLAN CARE 2 2.000000 74.3800 37.1900
PSTH-97161-PT EVAL LOW COMPLEXITY 3 3.000000 154.2300 51.4100
PSTH-97162-PT EVAL MODERATE COMPLEXITY 1 1.000000 51.4100 51.4100
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 4 4.000000 205.6400 51.4100
SPL-92526-TREATMENT OF SWALLOWING DYSFUNCTION 1 5.000000 219.6900 43.9380
Subtotal (Total Children Is Unduplicated) 21 29.500000 1660.6400 56.2929
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 2 4.000000 5515.6000 1378.9000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 6 19.000000 950.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 26 146.000000 9600.5400 65.7571
OCCT-97530GT-OT SESSION BY LICENSED OT 4 24.250000 1745.0300 71.9600
PHY-97110-PT SESSION BY LICENSED PT 22 117.500000 7546.2100 64.2231
PHY-97110GT-PT SESSION BY LICENSED PT 1 2.250000 161.9100 71.9600
SENS-V5264-EARMOLD 1 1.000000 18.1300 18.1300
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 37 182.500000 12878.5200 70.5672
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 1 1.000000 71.9600 71.9600
Subtotal (Total Children Is Unduplicated) 69 497.500000 38487.9000 77.3626
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Total 527.000000 40148.5400 76.1832
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Number of Children (Unduplicated) With at Least One Service 75
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Center 02
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 0 0.000000 0.0000 0.0000
D 0 0.000000 0.0000 0.0000
S 3 3.000000 99.4600 -116.4200
H 0 0.000000 0.0000 0.0000
T 582 416.250000 33110.2900 33788.6760
139 107.750000 6938.7900 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 724 527.000000 40148.5400 33672.2560