CMS/EIP Fiscal Report Center: 04
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
EVAL-96111-DEVELOPMENTAL EVALUATION 1 1.000000 50.0000 50.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 1 1.000000 75.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 11 12.000000 900.0000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 11 14.000000 1030.5000 73.6071
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 1.000000 55.5000 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 3 5.500000 305.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 14 15.500000 1162.5000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 2 2.000000 150.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 1 1.000000 75.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 2 3.000000 225.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 16 20.500000 1137.7500 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 5 7.000000 388.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 211 271.500000 20362.5000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 111 126.500000 9458.2500 74.7688
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 97 98.000000 29336.3000 299.3500
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 3 3.000000 417.4700 139.1567
OCTF-97168-OT RE-EVAL EST PLAN CARE 1 1.000000 51.4100 51.4100
OCTH-97165-OT EVAL LOW COMPLEXITY 34 41.000000 1975.1000 48.1732
OCTH-97167-OT EVAL HIGH COMPLEXITY 6 6.000000 308.4600 51.4100
PSTF-97164-PT RE-EVAL EST PLAN CARE 3 3.000000 154.2300 51.4100
PSTH-97161-PT EVAL LOW COMPLEXITY 22 27.000000 1307.3900 48.4219
PSTH-97162-PT EVAL MODERATE COMPLEXITY 1 1.000000 51.4100 51.4100
PSTH-97163-PT EVAL HIGH COMPLEXITY 6 7.000000 359.8700 51.4100
SPCH-92521-EVAL OF SPEECH FLUENCY 32 41.000000 2106.7300 51.3837
SPCH-92521GT-EVAL OF SPEECH FLUENCY 4 4.000000 205.6400 51.4100
SPCH-92521TL-EVAL OF SPEECH FLUENCY 1 1.000000 51.4100 51.4100
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 5 5.000000 257.0500 51.4100
Subtotal (Total Children Is Unduplicated) 409 719.500000 71958.2200 100.0114
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1 5.000000 250.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 45 493.500000 34274.6200 69.4521
OCCT-97530HM-OT SESSION BY OT ASST 8 65.000000 3744.0000 57.6000
PHY-97110-PT SESSION BY LICENSED PT 34 440.500000 29844.6100 67.7517
PHY-97110HM-PT SESSION BY PT ASST 19 49.750000 2858.8100 57.4635
PHY-97110TL-PT SESSION BY LICENSED PT 2 17.000000 1223.3200 71.9600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 54 504.750000 35657.9300 70.6447
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 1 0.500000 35.9800 71.9600
Subtotal (Total Children Is Unduplicated) 120 1576.000000 107889.2700 68.4577
-----------------------------------------------------------------------------------------------------------------------
Total 2295.500000 179847.4900 78.3479
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 439
-----------------------------------------------------------------------------------------------------------------------
Center 04
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 588 1124.500000 82000.3100 61231.5300
D 3 8.000000 518.2400 107.9400
S 2 7.500000 209.4600 0.0000
H 4 7.500000 453.5400 0.0000
T 0 0.000000 0.0000 0.0000
416 471.000000 49668.8700 831.0800
Other 321 677.000000 46997.0700 1180.2800
---------------------------------------------------------
Total 1334 2295.500000 179847.4900 63350.8300