CMS/EIP Fiscal Report Center: 53
Services beginning 04/01/2022 ending 06/30/2022 Date of Report:08/08/2022 Page: 1
List order: No List
Payclass Filters:MED
Eligibility Filter:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 857 2132.750000 78911.7500 37.0000
Subtotal (Total Children Is Unduplicated) 857 2132.750000 78911.7500 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 3 5.000000 375.0000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 5 8.500000 637.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 1.500000 112.5000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 1 1.500000 112.5000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 2 3.500000 262.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 5 8.000000 444.0000 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 6 11.500000 638.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 6 11.500000 862.5000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 77 143.000000 10725.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 5 7.500000 562.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 68 127.000000 9525.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 6 10.500000 787.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 55 95.000000 7125.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 25 39.000000 2164.5000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 185 328.000000 18204.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 5 11.000000 825.0000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 27 46.000000 3450.0000 75.0000
Subtotal (Total Children Is Unduplicated) 262 858.000000 56813.2500 66.2159
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 254 917.250000 45862.5000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 318 1154.000000 57700.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 10 13.500000 964.4400 71.4400
OCCT-97530GT-OT SESSION BY LICENSED OT 4 4.500000 321.4800 71.4400
OCCT-97530TL-OT SESSION BY LICENSED OT 32 98.500000 7036.8400 71.4400
OCCT-97530TLGT-OT SESSION BY LICENSED OT 33 85.500000 6108.1200 71.4400
PHY-97110-PT SESSION BY LICENSED PT 5 19.000000 1357.3600 71.4400
PHY-97110GT-PT SESSION BY LICENSED PT 3 2.000000 142.8800 71.4400
PHY-97110TL-PT SESSION BY LICENSED PT 34 150.750000 10769.5800 71.4400
PHY-97110TLGT-PT SESSION BY LICENSED PT 16 26.250000 1875.3000 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 3 6.000000 428.6400 71.4400
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 7 8.000000 571.5200 71.4400
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 41 132.000000 9430.0800 71.4400
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 52 166.250000 11876.9000 71.4400
Subtotal (Total Children Is Unduplicated) 558 2783.500000 154445.6400 55.4861
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Total 5774.250000 290170.6400 50.2525
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Number of Children (Unduplicated) With at Least One Service 990
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Center 53
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 19 28.500000 1916.0100 0.0000
P 670 728.250000 39823.6300 39823.6300
D 46 39.500000 2563.5800 0.0000
S 237 147.750000 5598.2500 0.0000
H 58 56.750000 2568.5100 0.0000
T 0 0.000000 0.0000 0.0000
4928 4752.750000 236683.7200 0.0000
Other 31 20.750000 1016.9400 0.0000
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Total 5989 5774.250000 290170.6400 39823.6300