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:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 695 1608.750000 59477.5000 36.9713
Subtotal (Total Children Is Unduplicated) 695 1608.750000 59477.5000 36.9713
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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 4 7.500000 562.5000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 8 14.500000 1087.5000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 7 12.500000 937.5000 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-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 25.500000 1415.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 10 20.500000 1537.5000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 58 110.500000 8287.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 6 10.000000 750.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 45 79.500000 5962.5000 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 38 63.000000 4725.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 11 18.500000 1026.7500 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 124 216.500000 12015.7500 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 11 22.500000 1687.5000 75.0000
Subtotal (Total Children Is Unduplicated) 196 633.000000 42356.2500 66.9135
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 301 1037.250000 51862.5000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 229 641.000000 32050.0000 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) 516 2311.750000 129241.8900 55.9065
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Total 4553.500000 231075.6400 50.7468
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Number of Children (Unduplicated) With at Least One Service 893
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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 55 58.000000 3712.4600 0.0000
S 82 73.000000 3980.8400 0.0000
H 1 1.000000 71.4400 0.0000
T 0 0.000000 0.0000 0.0000
1755 1769.750000 91823.3500 0.0000
Other 68 48.750000 1973.2500 9.2500
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Total 4707 4553.500000 231075.6400 57610.8800