CMS/EIP Fiscal Report Center: 01
Services beginning 10/01/2022 ending 12/31/2022 Date of Report:01/23/2023 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 1184 1942.750000 72266.5500 37.1981
Subtotal (Total Children Is Unduplicated) 1184 1942.750000 72266.5500 37.1981
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 1.500000 112.5000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 2 5.500000 412.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 1.500000 83.2500 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 2 3.500000 91.5000 26.1429
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 13 21.000000 1575.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 16 25.000000 1875.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 7 11.500000 862.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 2 3.000000 225.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 17 30.000000 2250.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 5 8.000000 600.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 36 62.000000 3441.0000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 45 72.500000 4023.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 54 123.000000 9225.0000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 51 111.000000 8325.0000 75.0000
SPCH-92610-EVAL OF ORAL,PHARYNGEAL SWALLOWING FUNC 1 1.000000 44.8600 44.8600
SPL-92526TL-TREATMENT OF SWALLOWING DYSFUNCTION 1 4.000000 211.7200 52.9300
Subtotal (Total Children Is Unduplicated) 149 484.000000 33358.5800 68.9227
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 48 103.000000 5150.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 19 26.000000 1300.0000 50.0000
OCCT-97530TL-OT SESSION BY LICENSED OT 8 18.000000 1295.2800 71.9600
PHY-97110-PT SESSION BY LICENSED PT 1 1.000000 71.9600 71.9600
PHY-97110TL-PT SESSION BY LICENSED PT 19 51.000000 3669.9600 71.9600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 4 9.000000 504.7600 56.0844
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 1 4.000000 287.8400 71.9600
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 7 12.750000 917.4900 71.9600
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 4 9.000000 647.6400 71.9600
Subtotal (Total Children Is Unduplicated) 95 233.750000 13844.9300 59.2296
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Total 2660.500000 119470.0600 44.9051
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Number of Children (Unduplicated) With at Least One Service 1245
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Center 01
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 0 0.000000 0.0000 0.0000
P 0 0.000000 0.0000 0.0000
D 59 60.000000 3100.7500 0.0000
S 3583 2420.750000 104391.5200 0.0000
H 0 0.000000 0.0000 0.0000
T 2 2.000000 1.0400 1.0400
0 0.000000 0.0000 0.0000
Other 129 177.750000 11976.7500 0.0000
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Total 3773 2660.500000 119470.0600 1.0400