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
Agency Filter:EIP DEI DEIP
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 4 7.000000 525.0000 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 5 9.000000 499.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 5 9.000000 675.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 41 75.500000 5662.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 2 3.500000 262.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 22 41.000000 3075.0000 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 2 4.000000 222.0000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 64 116.500000 6465.7500 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 11.500000 862.5000 75.0000
Subtotal (Total Children Is Unduplicated) 131 363.000000 24699.7500 68.0434
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 108 352.000000 17600.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 95 236.250000 11812.5000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 6 7.000000 500.0800 71.4400
OCCT-97530TL-OT SESSION BY LICENSED OT 14 38.500000 2754.3400 71.5413
OCCT-97530TLGT-OT SESSION BY LICENSED OT 3 4.000000 285.7600 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) 261 1165.000000 70687.6700 60.6761
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Total 2867.000000 144921.1700 50.5480
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Number of Children (Unduplicated) With at Least One Service 717
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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
466 426.750000 21985.6300 0.0000
Other 63 44.250000 1674.2500 9.2500
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Total 3130 2867.000000 144921.1700 49636.3800