CMS/EIP Fiscal Report Center: 51
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
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 1.000000 75.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 1.000000 75.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 1.000000 55.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 1 1.000000 75.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 8 10.000000 555.0000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 1 1.000000 55.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 9 9.500000 712.5000 75.0000
OCTH-97165-OT EVAL LOW COMPLEXITY 6 6.000000 308.4600 51.4100
OCTH-97166-OT EVAL MODERATE COMPLEXITY 1 1.000000 51.0500 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 5 5.000000 256.3300 51.2660
PSTH-97161-PT EVAL LOW COMPLEXITY 4 4.000000 178.9800 44.7450
PSTH-97162-PT EVAL MODERATE COMPLEXITY 2 2.000000 102.8200 51.4100
SPCH-92521-EVAL OF SPEECH FLUENCY 6 6.000000 308.1000 51.3500
SPCH-92521GT-EVAL OF SPEECH FLUENCY 1 1.000000 51.4100 51.4100
SPCH-92523GT-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 1 1.000000 51.4100 51.4100
Subtotal (Total Children Is Unduplicated) 38 50.500000 2912.0600 57.6646
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 10 65.000000 3250.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 1 3.000000 150.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 4 11.000000 110.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 45 438.250000 29856.0500 68.1256
OCCT-97530GT-OT SESSION BY LICENSED OT 9 42.000000 2560.8200 60.9719
OCCT-97530HM-OT SESSION BY OT ASST 21 220.250000 12672.8000 57.5383
OCCT-97530HMGT-OT SESSION BY OT ASST 4 10.500000 604.8000 57.6000
PHY-97110-PT SESSION BY LICENSED PT 15 246.250000 17060.4200 69.2809
PHY-97110GT-PT SESSION BY LICENSED PT 1 2.000000 143.9200 71.9600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 67 855.500000 59988.0800 70.1205
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 1 2.000000 143.9200 71.9600
Subtotal (Total Children Is Unduplicated) 107 1895.750000 126540.8100 66.7497
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Total 1946.250000 129452.8700 66.5140
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Number of Children (Unduplicated) With at Least One Service 117
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Center 51
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 613 1844.750000 122919.8100 122919.8100
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 3 14.000000 964.3600 964.3600
T 0 0.000000 0.0000 0.0000
31 87.500000 5568.7000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 647 1946.250000 129452.8700 123884.1700