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
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 957 3426.500000 127280.3500 37.1459
Subtotal (Total Children Is Unduplicated) 957 3426.500000 127280.3500 37.1459
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 3 5.000000 375.0000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 7 13.500000 1012.5000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 12 22.500000 1687.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 4 7.000000 525.0000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 4 8.000000 600.0000 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 4 8.000000 600.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 4 7.000000 388.5000 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 16 31.000000 1720.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 11 17.500000 1312.5000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 36 75.000000 5625.0000 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 57 105.500000 7912.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 13 22.500000 1650.0000 73.3333
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 29 51.500000 3862.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 20 38.000000 2109.0000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 101 196.500000 10905.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 12 23.500000 1762.5000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 52 107.500000 8062.5000 75.0000
Subtotal (Total Children Is Unduplicated) 231 784.500000 53486.2500 68.1788
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 301 1187.750000 59387.5000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 230 636.750000 31837.5000 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 20 56.000000 4029.7600 71.9600
PHY-97110GT-PT SESSION BY LICENSED PT 1 1.000000 71.9600 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 26 89.000000 6404.4400 71.9600
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 3 3.000000 215.8800 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) 580 2624.000000 148637.0600 56.6452
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Total 6835.000000 329403.6600 48.1937
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Number of Children (Unduplicated) With at Least One Service 995
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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 74 77.500000 4419.6800 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
1750 1879.500000 98457.8100 0.0000
Other 115 90.750000 4057.7600 1285.9500
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Total 7235 6835.000000 329403.6600 169071.5700