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:OTHER
Eligibility Filter:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
CASE-CASE-NON-TCM CASE MANAGEMENT 1 0.250000 9.3000 37.2000
TCM-T1017TL-TARGETED CASE MANAGEMENT 44 90.250000 3348.9500 37.1075
Subtotal (Total Children Is Unduplicated) 44 90.500000 3358.2500 37.1077
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Screening, Eval, and Assessment,Class #02
EVAL-96111-DEVELOPMENTAL EVALUATION 1 2.000000 100.0000 50.0000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 7 14.000000 1050.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 4 8.000000 600.0000 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 1 2.000000 111.0000 55.5000
PSTF-97164-PT RE-EVAL EST PLAN CARE 1 1.000000 51.4100 51.4100
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 1 1.000000 51.4100 51.4100
Subtotal (Total Children Is Unduplicated) 14 30.000000 2074.8200 69.1607
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1 4.000000 200.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 1 6.000000 431.7600 71.9600
OCCT-97530HM-OT SESSION BY OT ASST 6 18.000000 1036.8000 57.6000
PHY-97110-PT SESSION BY LICENSED PT 1 3.000000 215.8800 71.9600
PHY-97110HM-PT SESSION BY PT ASST 1 3.000000 172.6800 57.5600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 10 39.000000 2806.4400 71.9600
Subtotal (Total Children Is Unduplicated) 19 73.000000 4863.5600 66.6241
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Total 193.500000 10296.6300 53.2126
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Number of Children (Unduplicated) With at Least One Service 62
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Center 55
Flag Claims Units Chgs Paid
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R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 0 0.000000 0.0000 0.0000
P 56 55.000000 3635.5700 3635.5700
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
150 138.500000 6661.0600 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 206 193.500000 10296.6300 3635.5700