CMS/EIP Fiscal Report Center: 09
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 1043 3741.000000 139013.1000 37.1593
Subtotal (Total Children Is Unduplicated) 1043 3741.000000 139013.1000 37.1593
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 2.000000 150.0000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 4 9.500000 673.5000 70.8947
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 6 10.500000 758.2500 72.2143
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 2 4.000000 300.0000 75.0000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 7 13.000000 721.5000 55.5000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 134 255.000000 19125.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 76 145.000000 10875.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 58 112.000000 8400.0000 75.0000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 180 343.500000 19064.2500 55.5000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 25 48.500000 3637.5000 75.0000
OCTH-97166GT-OT EVAL MODERATE COMPLEXITY 1 1.000000 51.4100 51.4100
OCTH-97166TLGT-OT EVAL MODERATE COMPLEXITY 1 1.000000 51.4100 51.4100
SPCH-92521-EVAL OF SPEECH FLUENCY 5 5.000000 255.6100 51.1220
SPCH-92523TLGT-EVAL OF SPCH SOUND PROD; EVAL LANG COM 1 1.000000 51.4100 51.4100
Subtotal (Total Children Is Unduplicated) 246 953.000000 64264.8400 67.4343
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 686 4955.750000 247737.5000 49.9899
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 35 116.000000 5800.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 55 313.000000 22523.4800 71.9600
OCCT-97530GT-OT SESSION BY LICENSED OT 2 5.750000 413.7700 71.9600
OCCT-97530TL-OT SESSION BY LICENSED OT 1 1.000000 71.9600 71.9600
OCCT-97530TLGT-OT SESSION BY LICENSED OT 8 27.000000 1942.9200 71.9600
PHY-97110-PT SESSION BY LICENSED PT 36 236.000000 16756.8800 71.0037
PHY-97110GT-PT SESSION BY LICENSED PT 2 7.000000 503.7200 71.9600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 86 647.000000 46414.2000 71.7376
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 4 13.000000 935.4800 71.9600
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 7 23.000000 1655.0800 71.9600
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 2 10.750000 773.5700 71.9600
SPL-92508TLGT-SPL THERAPY SESSION BY LICENSED SLP 1 1.000000 13.9600 13.9600
Subtotal (Total Children Is Unduplicated) 804 6356.250000 345542.5200 54.3626
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Total 11050.250000 548820.4600 49.6659
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Number of Children (Unduplicated) With at Least One Service 1205
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Center 09
Flag Claims Units Chgs Paid
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R 8 6.000000 259.8000 0.0000
U 0 0.000000 0.0000 0.0000
B 1792 2024.750000 82251.6700 5241.5600
P 2103 2308.750000 93369.8200 93151.4800
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 6 3.000000 111.6000 111.0000
1941 6416.750000 352782.6200 0.0000
Other 154 291.000000 20044.9500 0.0000
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Total 6004 11050.250000 548820.4600 98504.0400