CMS/EIP Fiscal Report Center: 55
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 651 2105.000000 78219.3000 37.1588
Subtotal (Total Children Is Unduplicated) 651 2105.000000 78219.3000 37.1588
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 13 26.000000 1950.0000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 1 2.000000 150.0000 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 6 12.000000 900.0000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 2.000000 150.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 3 6.000000 333.0000 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 1 2.000000 111.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 112 228.000000 17100.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 19 37.333333 2800.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 9 18.000000 1350.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 4 8.000000 600.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 15 30.000000 2250.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 11 22.000000 1650.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 63 128.000000 7104.0000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 14 28.000000 1554.0000 55.5000
OCTF-97168-OT RE-EVAL EST PLAN CARE 14 15.000000 771.1500 51.4100
OCTH-97167-OT EVAL HIGH COMPLEXITY 12 12.000000 616.9200 51.4100
OCTH-97167GT-OT EVAL HIGH COMPLEXITY 1 1.000000 51.4100 51.4100
OCTH-97167TLGT-OT EVAL HIGH COMPLEXITY 1 2.000000 102.8200 51.4100
PSTF-97164-PT RE-EVAL EST PLAN CARE 2 2.000000 102.8200 51.4100
PSTH-97163-PT EVAL HIGH COMPLEXITY 2 2.000000 102.8200 51.4100
PSTH-97163GT-PT EVAL HIGH COMPLEXITY 1 1.000000 51.4100 51.4100
SPCH-92521-EVAL OF SPEECH FLUENCY 1 1.000000 51.4100 51.4100
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 8 8.000000 411.2800 51.4100
SPCH-92610-EVAL OF ORAL,PHARYNGEAL SWALLOWING FUNC 1 1.000000 44.8600 44.8600
Subtotal (Total Children Is Unduplicated) 193 598.333333 40608.9000 67.8700
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 183 1286.250000 64312.5000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 14 82.500000 4125.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 53 299.500000 21552.0200 71.9600
OCCT-97530GT-OT SESSION BY LICENSED OT 1 8.000000 575.6800 71.9600
OCCT-97530HM-OT SESSION BY OT ASST 76 539.250000 31060.8000 57.6000
OCCT-97530HMGT-OT SESSION BY OT ASST 1 4.000000 230.4000 57.6000
OCCT-97530TLHM-OT SESSION BY OT ASST 2 26.000000 1497.6000 57.6000
PHY-97110-PT SESSION BY LICENSED PT 29 199.000000 14320.0400 71.9600
PHY-97110GT-PT SESSION BY LICENSED PT 1 7.000000 503.7200 71.9600
PHY-97110HM-PT SESSION BY PT ASST 42 282.750000 16275.0900 57.5600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 94 507.250000 36501.7100 71.9600
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 2 9.750000 701.6100 71.9600
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 2 37.000000 2662.5200 71.9600
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 1 1.000000 71.9600 71.9600
Subtotal (Total Children Is Unduplicated) 393 3289.250000 194390.6500 59.0988
-----------------------------------------------------------------------------------------------------------------------
Total 5992.583333 313218.8500 52.2678
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 691
-----------------------------------------------------------------------------------------------------------------------
Center 55
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 2053 1819.250000 80171.9100 0.0000
P 903 860.500000 35522.1500 35522.0000
D 0 0.000000 0.0000 0.0000
S 1 1.333333 100.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
3217 3311.500000 197424.7900 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 6174 5992.583333 313218.8500 35522.0000