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
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 1978 8876.250000 328384.2500 36.9958
Subtotal (Total Children Is Unduplicated) 1978 8876.250000 328384.2500 36.9958
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 7 13.000000 975.0000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 19 34.500000 2587.5000 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 17 29.000000 2175.0000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 6 10.500000 787.5000 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 10 17.500000 971.2500 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 42 81.500000 4523.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 13 23.500000 1762.5000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 311 556.000000 41700.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 17 28.500000 2137.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 272 491.500000 36862.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 9 15.000000 1125.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 150 247.000000 18525.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 52 82.500000 4578.7500 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 574 1009.000000 55999.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 7 14.000000 1050.0000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 108 195.500000 14662.5000 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) 887 2869.000000 191888.4000 66.8834
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 354 1780.250000 89012.5000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 691 6707.500000 335362.0000 49.9981
OCCT-97530-OT SESSION BY LICENSED OT 32 68.000000 4857.9200 71.4400
OCCT-97530GT-OT SESSION BY LICENSED OT 19 48.750000 3482.7000 71.4400
OCCT-97530TL-OT SESSION BY LICENSED OT 42 222.750000 15913.2600 71.4400
OCCT-97530TLGT-OT SESSION BY LICENSED OT 88 515.250000 36809.4600 71.4400
PHY-97110-PT SESSION BY LICENSED PT 14 43.750000 3125.5000 71.4400
PHY-97110GT-PT SESSION BY LICENSED PT 13 20.000000 1428.8000 71.4400
PHY-97110TL-PT SESSION BY LICENSED PT 55 342.250000 24450.3400 71.4400
PHY-97110TLGT-PT SESSION BY LICENSED PT 51 208.250000 14877.3800 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 17 29.000000 2071.7600 71.4400
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 11 13.000000 928.7200 71.4400
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 70 349.800000 24989.0000 71.4380
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 129 1014.250000 72400.4600 71.3832
Subtotal (Total Children Is Unduplicated) 1023 11362.80000 629709.8000 55.4185
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Total 23108.050000 1149982.4500 49.7654
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Number of Children (Unduplicated) With at Least One Service 2037
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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 233 218.000000 14847.5300 0.0000
S 348 227.250000 8954.1900 0.0000
H 158 141.000000 7173.1900 9.2500
T 0 0.000000 0.0000 0.0000
10385 10324.500000 525332.5900 0.0000
Other 276 210.000000 9928.0000 296.0000
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Total 24189 23108.050000 1149982.4500 573515.0000