CMS/EIP Fiscal Report Center: 53
Services beginning 07/01/2022 ending 09/30/2022 Date of Report:10/18/2022 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 533 1271.750000 47045.5000 36.9927
Subtotal (Total Children Is Unduplicated) 533 1271.750000 47045.5000 36.9927
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 2 4.000000 300.0000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 3 6.000000 450.0000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 3 5.500000 412.5000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 5 9.500000 712.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 2.000000 150.0000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 3 6.000000 450.0000 75.0000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 8 15.000000 832.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 8 15.000000 1125.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 43 77.500000 5812.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 4 6.000000 450.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 14 26.000000 1950.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 7 12.500000 937.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 22 34.500000 2587.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 3 5.000000 277.5000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 65 116.500000 6465.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 2 4.000000 300.0000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 10 19.000000 1425.0000 75.0000
Subtotal (Total Children Is Unduplicated) 144 364.000000 24638.2500 67.6875
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 103 319.000000 15950.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 89 208.250000 10412.5000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 6 7.000000 500.0800 71.4400
OCCT-97530TL-OT SESSION BY LICENSED OT 11 29.000000 2071.7600 71.4400
OCCT-97530TLGT-OT SESSION BY LICENSED OT 3 4.000000 285.7600 71.4400
PHY-97110-PT SESSION BY LICENSED PT 6 7.000000 500.0800 71.4400
PHY-97110GT-PT SESSION BY LICENSED PT 1 2.000000 142.8800 71.4400
PHY-97110TL-PT SESSION BY LICENSED PT 34 184.750000 13209.4600 71.4991
PHY-97110TLGT-PT SESSION BY LICENSED PT 10 16.500000 1178.7600 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 5 7.000000 501.1200 71.5886
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 3 7.000000 500.0800 71.4400
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 42 117.500000 8411.4900 71.5871
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 25 58.250000 4166.5800 71.5293
Subtotal (Total Children Is Unduplicated) 244 967.250000 57830.5500 59.7886
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Total 2603.000000 129514.3000 49.7558
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Number of Children (Unduplicated) With at Least One Service 631
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Center 53
Flag Claims Units Chgs Paid
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R 65 59.500000 3278.9100 0.0000
U 0 0.000000 0.0000 0.0000
B 1392 1336.500000 68633.7600 9.2500
P 1289 1207.000000 57601.6300 57592.3800
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 2746 2603.000000 129514.3000 57601.6300