CMS/EIP Fiscal Report Center: 06
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 1090 3358.750000 124870.9500 37.1778
Subtotal (Total Children Is Unduplicated) 1090 3358.750000 124870.9500 37.1778
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 4 6.000000 450.0000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 2 3.000000 225.0000 75.0000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 2 3.000000 166.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 10 18.500000 1387.5000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 58 105.500000 7912.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 10 18.500000 1387.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 50 90.000000 6750.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 4 8.000000 600.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 35 66.500000 4987.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 20 37.000000 2053.5000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 99 185.000000 10267.5000 55.5000
Subtotal (Total Children Is Unduplicated) 147 541.000000 36187.5000 66.8900
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 676 4490.000000 224420.0000 49.9822
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 127 403.000000 20150.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 15 80.250000 5702.8300 71.0633
OCCT-97530GT-OT SESSION BY LICENSED OT 2 6.000000 395.7800 65.9633
OCCT-97530HM-OT SESSION BY OT ASST 5 18.250000 1050.6600 57.5704
OCCT-97530HMGT-OT SESSION BY OT ASST 2 2.000000 100.7800 50.3900
PHY-97110-PT SESSION BY LICENSED PT 16 70.500000 5019.2100 71.1945
PHY-97110GT-PT SESSION BY LICENSED PT 5 26.500000 1906.9400 71.9600
PHY-97110HM-PT SESSION BY PT ASST 10 40.750000 2345.5700 57.5600
PHY-97110HMGT-PT SESSION BY LICENSED PT ASST 5 11.000000 633.1600 57.5600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 10 64.000000 4584.9800 71.6403
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 19 69.250000 4947.2500 71.4404
Subtotal (Total Children Is Unduplicated) 775 5281.500000 271257.1600 51.3599
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Total 9181.250000 432315.6100 47.0868
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Number of Children (Unduplicated) With at Least One Service 1181
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Center 06
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 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
10470 9181.250000 432315.6100 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 10470 9181.250000 432315.6100 0.0000