CMS/EIP Fiscal Report Center: 01
Services beginning 01/01/2023 ending 03/31/2023 Date of Report:04/20/2023 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 1301 2111.000000 78529.2000 37.2000
Subtotal (Total Children Is Unduplicated) 1301 2111.000000 78529.2000 37.2000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 2.000000 150.0000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 2 3.500000 262.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 2 4.000000 300.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 3 5.500000 412.5000 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 5 11.000000 825.0000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 5 8.000000 600.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 7 11.500000 638.2500 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 6 9.500000 527.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 15 25.500000 1912.5000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 25 42.500000 3187.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 12 19.500000 1462.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 7 12.500000 937.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 15 28.500000 2137.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 20 31.500000 2362.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 84 141.500000 7853.2500 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 107 172.500000 9573.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 85 176.500000 13237.5000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 114 224.500000 16837.5000 75.0000
OCTH-97165TL-OT EVAL LOW COMPLEXITY 2 2.000000 102.8200 51.4100
SPCH-92521TL-EVAL OF SPEECH FLUENCY 1 1.000000 51.4100 51.4100
SPL-92526TL-TREATMENT OF SWALLOWING DYSFUNCTION 1 1.000000 52.9300 52.9300
Subtotal (Total Children Is Unduplicated) 290 936.000000 63574.6600 67.9216
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 46 113.000000 5650.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 19 43.000000 2150.0000 50.0000
OCCT-97530TL-OT SESSION BY LICENSED OT 11 34.250000 2464.6300 71.9600
OCCT-97530TLGT-OT SESSION BY LICENSED OT 2 5.000000 359.8000 71.9600
PHY-97110-PT SESSION BY LICENSED PT 2 3.000000 215.8800 71.9600
PHY-97110TL-PT SESSION BY LICENSED PT 19 63.000000 4533.4800 71.9600
PHY-97110TLGT-PT SESSION BY LICENSED PT 4 4.000000 287.8400 71.9600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 1 1.000000 71.9600 71.9600
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 4 12.000000 863.5200 71.9600
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 4 9.500000 683.6200 71.9600
Subtotal (Total Children Is Unduplicated) 89 287.750000 17280.7300 60.0547
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Total 3334.750000 159384.5900 47.7951
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Number of Children (Unduplicated) With at Least One Service 1342
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Center 01
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 0 0.000000 0.0000 0.0000
D 59 59.500000 3038.1700 0.0000
S 3993 2943.250000 134643.0200 0.0000
H 0 0.000000 0.0000 0.0000
T 1 1.000000 50.0000 50.0000
0 0.000000 0.0000 0.0000
Other 234 331.000000 21653.4000 0.0000
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Total 4287 3334.750000 159384.5900 50.0000