CMS/EIP Fiscal Report Center: 03
Services beginning 07/01/2022 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 5 9.000000 575.0000 63.8889
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 7 12.500000 937.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 2 3.000000 225.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 6 9.000000 499.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 80 147.000000 10608.4000 72.1660
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 1 2.000000 150.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 108 207.000000 14750.7600 71.2597
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 94 168.500000 12527.5000 74.3472
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 2 2.500000 145.5000 58.2000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 97 178.500000 9906.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 26 44.500000 3337.5000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 1.000000 75.0000 75.0000
OCTF-97168-OT RE-EVAL EST PLAN CARE 1 1.000000 51.4100 51.4100
OCTH-97165-OT EVAL LOW COMPLEXITY 1 1.000000 51.4100 51.4100
OCTH-97167GT-OT EVAL HIGH COMPLEXITY 2 2.000000 102.8200 51.4100
PSTF-97164-PT RE-EVAL EST PLAN CARE 2 2.000000 102.8200 51.4100
PSTH-97161-PT EVAL LOW COMPLEXITY 12 12.000000 616.9200 51.4100
PSTH-97162-PT EVAL MODERATE COMPLEXITY 5 5.000000 219.6400 43.9280
SCREEN-T1023-SCREENING 2 2.000000 100.0000 50.0000
SPCH-92521-EVAL OF SPEECH FLUENCY 9 9.000000 405.5500 45.0611
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 19 20.000000 1027.4800 51.3740
SPL-92526-TREATMENT OF SWALLOWING DYSFUNCTION 2 3.000000 158.7900 52.9300
Subtotal (Total Children Is Unduplicated) 372 843.500000 56675.2500 67.1906
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 1 1.000000 299.9900 299.9900
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 2 2.500000 125.0000 50.0000
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 40 48.000000 2400.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 167 408.000000 20400.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 320 2078.000000 103900.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 3 3.000000 30.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 13 73.750000 4771.9600 64.7045
OCCT-97530GT-OT SESSION BY LICENSED OT 6 6.000000 368.3100 61.3850
PHY-97110-PT SESSION BY LICENSED PT 44 311.500000 21537.8100 69.1422
PHY-97110GT-PT SESSION BY LICENSED PT 4 15.750000 1131.8100 71.8610
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 91 479.250000 29243.9500 61.0202
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 14 20.000000 1438.1600 71.9080
TRAV-TRAVS-Travel by mile 1 36.000000 16.0200 0.4450
Subtotal (Total Children Is Unduplicated) 506 3482.750000 185663.0100 53.3093
-----------------------------------------------------------------------------------------------------------------------
Total 4326.250000 242338.2600 56.0158
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 718
-----------------------------------------------------------------------------------------------------------------------
Center 03
Flag Claims Units Chgs Paid
---------------------------------------------------------
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 2780 2995.500000 166230.1200 166230.1200
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 244 279.250000 14928.0800 14928.0800
T 0 0.000000 0.0000 0.0000
906 1051.500000 61180.0600 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 3930 4326.250000 242338.2600 181158.2000