CMS/EIP Fiscal Report Center: 10
Services beginning 10/01/2022 ending 12/31/2022 Date of Report:01/23/2023 Page: 1
List order: No List
Payclass Filters:MED
Bill Flag Filter:RBPU
Eligibility Filter:All
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 1859 6179.500000 229777.4000 37.1838
Subtotal (Total Children Is Unduplicated) 1859 6179.500000 229777.4000 37.1838
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 3 5.500000 412.5000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 3 7.000000 525.0000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 2 3.500000 262.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 3 5.500000 305.2500 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 3 6.000000 333.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 109 192.000000 14400.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 117 220.500000 16537.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 38 63.500000 4762.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 65 120.000000 9000.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 39 73.000000 5475.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 26 49.500000 3712.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 125 230.500000 12792.7500 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 144 271.500000 15068.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 57 101.000000 7575.0000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 16 30.000000 2250.0000 75.0000
Subtotal (Total Children Is Unduplicated) 366 1383.000000 93711.7500 67.7598
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EI Services,Class #03
OCCT-97530-OT SESSION BY LICENSED OT 1 3.000000 215.8800 71.9600
OCCT-97530HM-OT SESSION BY OT ASST 1 1.250000 72.0000 57.6000
PHY-97110-PT SESSION BY LICENSED PT 1 2.000000 143.9200 71.9600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 1 7.000000 503.7200 71.9600
Subtotal (Total Children Is Unduplicated) 4 13.250000 935.5200 70.6053
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Total 7575.750000 324424.6700 42.8241
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Number of Children (Unduplicated) With at Least One Service 1869
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Center 10
Flag Claims Units Chgs Paid
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R 49 42.250000 1796.1000 0.0000
U 0 0.000000 0.0000 0.0000
B 8558 7520.250000 321693.0500 0.0000
P 4 13.250000 935.5200 137.5000
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
0 0.000000 0.0000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 8611 7575.750000 324424.6700 137.5000