CMS/EIP Fiscal Report Center: 04
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: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 1111 3983.000000 148089.6500 37.1804
Subtotal (Total Children Is Unduplicated) 1111 3983.000000 148089.6500 37.1804
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 1 1.000000 75.0000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 4 4.500000 337.5000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 2 1.500000 112.5000 75.0000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 8 9.000000 499.5000 55.5000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 77 87.500000 6562.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 84 87.000000 6525.0000 75.0000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 209 254.500000 14124.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 28 33.000000 2475.0000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 73 84.000000 6300.0000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 14 14.000000 1066.1000 76.1500
OCTH-97165-OT EVAL LOW COMPLEXITY 1 1.000000 51.4100 51.4100
OCTH-97167-OT EVAL HIGH COMPLEXITY 2 2.000000 102.8200 51.4100
PSTH-97161-PT EVAL LOW COMPLEXITY 2 2.000000 102.8200 51.4100
PSTH-97163-PT EVAL HIGH COMPLEXITY 1 1.000000 51.4100 51.4100
SPCH-92521-EVAL OF SPEECH FLUENCY 1 1.000000 51.4100 51.4100
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 2 2.000000 102.8200 51.4100
Subtotal (Total Children Is Unduplicated) 232 585.000000 38540.5400 65.8813
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 754 5392.000000 269350.0000 49.9536
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 39 179.000000 8950.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 15 68.000000 4838.3800 71.1526
OCCT-97530HM-OT SESSION BY OT ASST 8 44.000000 2534.4000 57.6000
PHY-97110-PT SESSION BY LICENSED PT 6 24.500000 1763.0200 71.9600
PHY-97110HM-PT SESSION BY PT ASST 10 54.000000 3102.0900 57.4461
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 3 8.500000 611.6600 71.9600
Subtotal (Total Children Is Unduplicated) 811 5770.000000 291149.5500 50.4592
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Total 10338.000000 477779.7400 46.2159
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Number of Children (Unduplicated) With at Least One Service 1366
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Center 04
Flag Claims Units Chgs Paid
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R 82 112.000000 4373.1000 0.0000
U 0 0.000000 0.0000 0.0000
B 1656 2451.250000 98190.0000 0.0000
P 842 1370.500000 54831.3000 50562.4000
D 54 69.500000 2805.0000 0.0000
S 1 0.750000 27.9000 0.0000
H 1557 5761.500000 290462.7400 100.0000
T 0 0.000000 0.0000 0.0000
462 572.500000 27089.7000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 4654 10338.000000 477779.7400 50662.4000