CMS/EIP Fiscal Report Center: 03
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
EXIT-EXIT-EXIT ASSESSMENT 2 2.000000 100.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 2 3.500000 262.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 4 6.500000 487.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 1.500000 112.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 4 7.000000 388.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 35 63.000000 4544.1700 72.1297
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 31 58.500000 4110.2200 70.2602
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 24 44.000000 3290.0000 74.7727
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 55 98.500000 5466.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 6 11.000000 825.0000 75.0000
OCTH-97167GT-OT EVAL HIGH COMPLEXITY 1 1.000000 51.4100 51.4100
PSTH-97161-PT EVAL LOW 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 4 4.000000 205.6400 51.4100
Subtotal (Total Children Is Unduplicated) 126 302.500000 19947.0100 65.9405
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EI Services,Class #03
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 8 8.000000 400.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 80 147.500000 7375.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 202 697.000000 34850.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 1 1.000000 10.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 3 5.000000 359.8000 71.9600
OCCT-97530GT-OT SESSION BY LICENSED OT 3 3.000000 215.8800 71.9600
PHY-97110-PT SESSION BY LICENSED PT 5 6.000000 431.7600 71.9600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 29 96.000000 5930.2400 61.7733
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 4 3.750000 269.8500 71.9600
TRAV-TRAVS-Travel by mile 1 36.000000 16.0200 0.4450
Subtotal (Total Children Is Unduplicated) 253 1003.250000 49858.5500 49.6970
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Total 1305.750000 69805.5600 53.4601
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Number of Children (Unduplicated) With at Least One Service 345
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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 217 275.750000 13239.3200 13239.3200
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 174 186.500000 9815.6000 9815.6000
T 0 0.000000 0.0000 0.0000
753 843.500000 46750.6400 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 1144 1305.750000 69805.5600 23054.9200