CMS/EIP Fiscal Report Center: 54
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 904 3242.250000 120471.4500 37.1567
Subtotal (Total Children Is Unduplicated) 904 3242.250000 120471.4500 37.1567
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 4 7.500000 562.5000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 9 16.500000 1237.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 3 5.000000 375.0000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 3 6.000000 450.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 4 8.000000 600.0000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 1 2.000000 150.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 2.000000 111.0000 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 7 13.500000 749.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 7 11.500000 862.5000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 19 35.500000 2662.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 22 37.000000 2775.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 54 99.500000 7462.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 11 19.000000 1425.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 20 34.500000 2587.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 1 1.500000 83.2500 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 31 61.000000 3385.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 10 20.000000 1500.0000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 46 89.500000 6712.5000 75.0000
Subtotal (Total Children Is Unduplicated) 188 469.500000 33691.5000 71.7604
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 73 210.000000 10500.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 73 201.000000 10050.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 9 13.000000 935.4800 71.9600
OCCT-97530GT-OT SESSION BY LICENSED OT 4 4.500000 323.8200 71.9600
OCCT-97530TL-OT SESSION BY LICENSED OT 49 213.750000 15381.4500 71.9600
OCCT-97530TLGT-OT SESSION BY LICENSED OT 22 44.500000 3202.2200 71.9600
PHY-97110-PT SESSION BY LICENSED PT 11 41.000000 2950.3600 71.9600
PHY-97110TL-PT SESSION BY LICENSED PT 42 173.250000 12467.0700 71.9600
PHY-97110TLGT-PT SESSION BY LICENSED PT 13 16.000000 1151.3600 71.9600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 4 4.000000 287.8400 71.9600
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 1 1.000000 71.9600 71.9600
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 30 111.500000 7961.5800 71.4043
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 15 42.000000 3022.3200 71.9600
Subtotal (Total Children Is Unduplicated) 259 1075.500000 68305.4600 63.5104
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Total 4787.250000 222468.4100 46.4710
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Number of Children (Unduplicated) With at Least One Service 930
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Center 54
Flag Claims Units Chgs Paid
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R 39 43.000000 2752.9200 0.0000
U 0 0.000000 0.0000 0.0000
B 1148 1093.750000 51758.8600 46.5000
P 4109 3650.500000 167956.6300 167739.1200
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 5296 4787.250000 222468.4100 167785.6200