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:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 1160 4226.000000 157129.2500 37.1816
Subtotal (Total Children Is Unduplicated) 1160 4226.000000 157129.2500 37.1816
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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 95 107.000000 8025.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 92 95.000000 7125.0000 75.0000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 248 300.000000 16650.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 37 42.000000 3150.0000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 84 93.500000 7012.5000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 17 17.000000 1294.5500 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) 272 679.500000 44744.2400 65.8488
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 756 5396.000000 269550.0000 49.9537
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 39 179.000000 8950.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 16 72.000000 5126.2200 71.1975
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) 814 5778.000000 291637.3900 50.4738
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Total 10683.500000 493510.8800 46.1937
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Number of Children (Unduplicated) With at Least One Service 1417
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Center 04
Flag Claims Units Chgs Paid
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R 86 118.000000 4671.9000 0.0000
U 0 0.000000 0.0000 0.0000
B 1782 2648.000000 106442.1000 0.0000
P 890 1451.500000 58265.2500 53938.1500
D 56 70.750000 2851.5000 0.0000
S 1 0.750000 27.9000 0.0000
H 1560 5769.500000 290950.5800 100.0000
T 0 0.000000 0.0000 0.0000
510 625.000000 30301.6500 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 4885 10683.500000 493510.8800 54038.1500