CMS/EIP Fiscal Report Center: 53
Services beginning 07/01/2021 ending 06/30/2022 Date of Report:08/08/2022 Page: 1
List order: No List
Payclass Filters:MED
Bill Flag Filter:RBPU
Eligibility Filter:All
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 1555 6471.250000 239399.2500 36.9943
Subtotal (Total Children Is Unduplicated) 1555 6471.250000 239399.2500 36.9943
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 6 11.500000 862.5000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 15 27.500000 2062.5000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 13 22.000000 1650.0000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 5 9.000000 675.0000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 8 16.000000 1200.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 2.000000 111.0000 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 13 23.500000 1304.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 9 15.500000 1162.5000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 259 456.500000 34237.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 12 20.500000 1537.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 159 290.000000 21750.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 5 9.000000 675.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 107 172.000000 12900.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 4 6.500000 360.7500 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 241 424.500000 23559.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 4 6.500000 487.5000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 95 172.500000 12937.5000 75.0000
SPCH-92522GT-EVAL OF SPCH SOUND PROD 1 1.000000 51.0500 51.0500
SPCH-92523TL-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 1 2.000000 102.1000 51.0500
Subtotal (Total Children Is Unduplicated) 677 1688.000000 117626.4000 69.6839
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 73 304.250000 15212.5000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 262 1873.750000 93687.5000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 16 32.250000 2303.9400 71.4400
OCCT-97530GT-OT SESSION BY LICENSED OT 9 25.500000 1821.7200 71.4400
OCCT-97530TL-OT SESSION BY LICENSED OT 20 74.250000 5304.4200 71.4400
OCCT-97530TLGT-OT SESSION BY LICENSED OT 54 255.250000 18235.0600 71.4400
PHY-97110-PT SESSION BY LICENSED PT 8 16.750000 1196.6200 71.4400
PHY-97110GT-PT SESSION BY LICENSED PT 6 11.000000 785.8400 71.4400
PHY-97110TL-PT SESSION BY LICENSED PT 34 165.250000 11805.4600 71.4400
PHY-97110TLGT-PT SESSION BY LICENSED PT 46 183.500000 13109.2400 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 13 22.000000 1571.6800 71.4400
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 6 6.000000 428.6400 71.4400
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 41 164.300000 11736.8800 71.4357
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 100 694.000000 49521.8000 71.3571
Subtotal (Total Children Is Unduplicated) 459 3828.050000 226721.3000 59.2263
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Total 11987.300000 583746.9500 48.6971
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Number of Children (Unduplicated) With at Least One Service 1639
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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 180 195.250000 11120.4100 710.7500
P 12609 11792.050000 572626.5400 572499.0000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
0 0.000000 0.0000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 12789 11987.300000 583746.9500 573209.7500