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
Agency Filter:EIP DEI DEIP
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 868 2931.000000 108936.1000 37.1669
Subtotal (Total Children Is Unduplicated) 868 2931.000000 108936.1000 37.1669
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 1.500000 112.5000 75.0000
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 7 13.000000 975.0000 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 3 6.000000 450.0000 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 4 8.000000 444.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 5 8.000000 600.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 14 27.500000 2062.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 18 33.000000 2475.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 37 69.000000 5175.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 8 16.000000 1200.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 13 24.000000 1800.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 1 2.000000 111.0000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 17 33.500000 1859.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 7 14.000000 1050.0000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 30 58.500000 4387.5000 75.0000
Subtotal (Total Children Is Unduplicated) 126 334.500000 24200.2500 72.3475
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 75 227.000000 11350.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 74 214.000000 10700.0000 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 50 222.750000 16029.0900 71.9600
OCCT-97530TLGT-OT SESSION BY LICENSED OT 22 44.500000 3202.2200 71.9600
PHY-97110-PT SESSION BY LICENSED PT 11 42.000000 3022.3200 71.9600
PHY-97110TL-PT SESSION BY LICENSED PT 45 191.250000 13762.3500 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 31 114.500000 8177.4600 71.4189
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 16 43.000000 3094.2800 71.9600
SPL-92508TLGT-SPL THERAPY SESSION BY LICENSED SLP 1 1.000000 13.9600 13.9600
Subtotal (Total Children Is Unduplicated) 265 1138.500000 72122.1400 63.3484
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Total 4404.000000 205258.4900 46.6073
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Number of Children (Unduplicated) With at Least One Service 884
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Center 54
Flag Claims Units Chgs Paid
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R 32 34.000000 2210.2200 0.0000
U 0 0.000000 0.0000 0.0000
B 1054 963.250000 45400.8100 9.3000
P 3722 3188.250000 147506.3300 147297.4200
D 60 58.750000 3326.4800 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
84 74.250000 3008.1400 0.0000
Other 111 85.500000 3806.5100 1147.2000
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Total 5063 4404.000000 205258.4900 148453.9200