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
Eligibility Filter:Part C (excluding not eligible)
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 626 1339.000000 49533.7500 36.9931
Subtotal (Total Children Is Unduplicated) 626 1339.000000 49533.7500 36.9931
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 2.000000 150.0000 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 6 11.000000 825.0000 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 1 2.000000 150.0000 75.0000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 7 12.500000 693.7500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 6 10.500000 787.5000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 42 82.000000 6150.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 4 7.500000 562.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 37 67.000000 5025.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 6 11.000000 825.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 28 48.000000 3600.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 7 12.500000 693.7500 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 88 156.500000 8685.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 3 5.500000 412.5000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 6 13.000000 975.0000 75.0000
Subtotal (Total Children Is Unduplicated) 141 458.500000 30848.2500 67.2808
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 300 1033.250000 51662.5000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 228 640.000000 32000.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 17 31.000000 2214.6400 71.4400
OCCT-97530GT-OT SESSION BY LICENSED OT 5 7.000000 500.0800 71.4400
OCCT-97530TL-OT SESSION BY LICENSED OT 21 53.250000 3808.0800 71.5132
OCCT-97530TLGT-OT SESSION BY LICENSED OT 8 15.000000 1071.6000 71.4400
PHY-97110-PT SESSION BY LICENSED PT 7 8.000000 571.5200 71.4400
PHY-97110GT-PT SESSION BY LICENSED PT 1 2.000000 142.8800 71.4400
PHY-97110TL-PT SESSION BY LICENSED PT 37 197.750000 14138.1800 71.4952
PHY-97110TLGT-PT SESSION BY LICENSED PT 11 17.500000 1250.2000 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 9 12.000000 859.3600 71.6133
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 4 8.000000 571.5200 71.4400
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 48 207.250000 14855.9900 71.6815
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 28 74.750000 5345.3400 71.5096
Subtotal (Total Children Is Unduplicated) 515 2306.750000 128991.8900 55.9193
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Total 4104.250000 209373.8900 51.0139
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Number of Children (Unduplicated) With at Least One Service 823
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Center 53
Flag Claims Units Chgs Paid
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R 62 54.500000 2933.1600 0.0000
U 0 0.000000 0.0000 0.0000
B 1273 1186.500000 61429.0100 9.2500
P 1139 1032.500000 49617.8800 49617.8800
D 54 56.000000 3601.4600 0.0000
S 72 65.500000 3608.3400 0.0000
H 1 1.000000 71.4400 0.0000
T 0 0.000000 0.0000 0.0000
1671 1664.000000 86438.3500 0.0000
Other 63 44.250000 1674.2500 9.2500
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Total 4335 4104.250000 209373.8900 49636.3800