CMS/EIP Fiscal Report Center: 57
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 1007 4116.250000 153093.7000 37.1925
Subtotal (Total Children Is Unduplicated) 1007 4116.250000 153093.7000 37.1925
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 9 15.000000 1125.0000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 7 13.000000 975.0000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 17 32.000000 1776.0000 55.5000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 173 309.000000 23145.7500 74.9053
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 45 80.000000 6000.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 43 71.500000 5362.5000 75.0000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 236 431.000000 23920.5000 55.5000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 23 36.500000 2737.5000 75.0000
OCTH-97165-OT EVAL LOW COMPLEXITY 1 1.000000 51.4100 51.4100
OCTH-97167-OT EVAL HIGH COMPLEXITY 2 2.000000 102.8200 51.4100
SPCH-92521-EVAL OF SPEECH FLUENCY 3 3.000000 154.2300 51.4100
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 1 1.000000 51.4100 51.4100
Subtotal (Total Children Is Unduplicated) 282 997.000000 65552.1200 65.7494
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 652 4326.250000 216312.5000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 50 151.500000 7575.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 16 75.285159 5417.5200 71.9600
OCCT-97530HM-OT SESSION BY OT ASST 4 14.000000 806.4000 57.6000
PHY-97110-PT SESSION BY LICENSED PT 6 24.000000 1727.0400 71.9600
PHY-97110HM-PT SESSION BY PT ASST 7 48.000000 2762.8800 57.5600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 8 58.000000 4173.6800 71.9600
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 5 30.000000 1728.0000 57.6000
Subtotal (Total Children Is Unduplicated) 691 4727.035159 240503.0200 50.8782
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Total 9840.285159 459148.8400 46.6601
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Number of Children (Unduplicated) With at Least One Service 1147
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Center 57
Flag Claims Units Chgs Paid
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R 148 213.750000 7951.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 2057 3058.500000 131236.5000 0.0000
P 909 1413.250000 63856.0900 63846.4960
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 88 138.250000 5199.6000 5082.9600
1286 4731.535159 240303.8000 239876.0000
Other 259 285.000000 10601.3500 0.0000
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Total 4747 9840.285159 459148.8400 308805.4560