CMS/EIP Fiscal Report Center: 55
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 10 16.308600 815.4300 50.0000
EVAL-96111GT-DEVELOPMENTAL EVALUATION 2 3.000000 150.0000 50.0000
EXIT-EXIT-EXIT ASSESSMENT 8 12.102600 605.1300 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 10 15.245866 1143.4400 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 6 10.079200 755.9400 75.0000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 290 502.528797 37689.6600 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 31 49.329600 3699.7200 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 44 79.811599 5985.8700 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 12 23.000000 1725.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 58 108.642533 8148.1900 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 9 16.067867 1205.0900 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 3 5.143782 285.4800 55.5000
OCTF-97168-OT RE-EVAL EST PLAN CARE 16 20.566032 1055.5600 51.3254
OCTH-97165-OT EVAL LOW COMPLEXITY 1 0.914397 46.6800 51.0500
OCTH-97166-OT EVAL MODERATE COMPLEXITY 3 4.141412 212.5500 51.3231
OCTH-97167-OT EVAL HIGH COMPLEXITY 38 41.194514 2115.6500 51.3576
OCTH-97167GT-OT EVAL HIGH COMPLEXITY 2 2.000000 102.4600 51.2300
PSTF-97164-PT RE-EVAL EST PLAN CARE 12 12.890891 661.7500 51.3347
PSTF-97164GT-PT RE-EVAL EST PLAN CARE 1 1.000000 51.4100 51.4100
PSTH-97162-PT EVAL MODERATE COMPLEXITY 1 1.000000 51.4100 51.4100
PSTH-97163-PT EVAL HIGH COMPLEXITY 9 10.000000 513.3800 51.3380
SPCH-92521-EVAL OF SPEECH FLUENCY 1 1.000000 51.4100 51.4100
SPCH-92521GT-EVAL OF SPEECH FLUENCY 1 1.000000 51.4100 51.4100
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 27 30.059148 1544.6600 51.3874
SPCH-92523GT-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 1 1.000000 51.4100 51.4100
Subtotal (Total Children Is Unduplicated) 408 968.026838 68718.6900 70.9884
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 5 9.000000 450.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 5 11.000000 110.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 55 682.898352 49094.3400 71.8911
OCCT-97530GT-OT SESSION BY LICENSED OT 1 2.000000 143.9200 71.9600
OCCT-97530HM-OT SESSION BY OT ASST 60 1323.493642 76160.7200 57.5452
OCCT-97530HMGT-OT SESSION BY OT ASST 1 1.000000 57.2000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 35 704.509934 50624.9100 71.8583
PHY-97110GT-PT SESSION BY LICENSED PT 2 3.000000 215.8800 71.9600
PHY-97110HM-PT SESSION BY PT ASST 29 315.392379 18130.4500 57.4854
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 85 942.789457 67771.4700 71.8840
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 2 2.750000 197.5000 71.8182
Subtotal (Total Children Is Unduplicated) 215 3997.833764 262956.3900 65.7747
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Total 4965.860602 331675.0800 66.7911
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Number of Children (Unduplicated) With at Least One Service 502
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Center 55
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 1799 1898.897754 127309.1000 127309.1000
D 0 0.000000 0.0000 0.0000
S 1 0.833333 62.5000 0.0000
H 183 299.665509 21909.9900 0.0000
T 0 0.000000 0.0000 0.0000
2903 2766.464006 182393.4900 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 4886 4965.860602 331675.0800 127309.1000