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:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 1145 3608.750000 134170.4000 37.1792
Subtotal (Total Children Is Unduplicated) 1145 3608.750000 134170.4000 37.1792
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 7 11.000000 825.0000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 3 4.500000 337.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 1.500000 112.5000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 1 1.500000 112.5000 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 5 8.000000 444.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 14 23.000000 1725.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 80 143.000000 10725.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 14 25.000000 1875.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 64 110.000000 8250.0000 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 43 79.000000 5925.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 25 44.500000 2469.7500 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 124 227.500000 12626.2500 55.5000
Subtotal (Total Children Is Unduplicated) 193 688.000000 46110.7500 67.0214
-----------------------------------------------------------------------------------------------------------------------
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
-----------------------------------------------------------------------------------------------------------------------
Total 9578.250000 451538.3100 47.1420
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 1237
-----------------------------------------------------------------------------------------------------------------------
Center 06
Flag Claims Units Chgs Paid
---------------------------------------------------------
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
10789 9578.250000 451538.3100 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 10789 9578.250000 451538.3100 0.0000