CMS/EIP Fiscal Report Center: 06
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:Part C (excluding not eligible)
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 1138 3655.500000 135964.9000 37.1946
Subtotal (Total Children Is Unduplicated) 1138 3655.500000 135964.9000 37.1946
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 1 2.000000 150.0000 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 2 4.000000 222.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 14 26.000000 1950.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 97 175.000000 13125.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 8 14.500000 1087.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 96 171.000000 12825.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 4 8.000000 600.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 50 93.500000 7012.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 15 27.000000 1498.5000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 154 288.000000 15984.0000 55.5000
MED-99205-OUTPATIENT VISIT, NEW, 60 MINS 1 1.000000 142.2300 142.2300
Subtotal (Total Children Is Unduplicated) 223 812.000000 54746.7300 67.4221
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 688 4219.000000 210870.0000 49.9810
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 90 307.000000 15305.0000 49.8534
OCCT-97530-OT SESSION BY LICENSED OT 11 39.750000 2788.4500 70.1497
OCCT-97530GT-OT SESSION BY LICENSED OT 10 15.750000 1133.3700 71.9600
OCCT-97530HM-OT SESSION BY OT ASST 4 12.750000 734.3600 57.5969
OCCT-97530HMGT-OT SESSION BY OT ASST 1 2.000000 115.2000 57.6000
PHY-97110-PT SESSION BY LICENSED PT 17 66.750000 4803.3300 71.9600
PHY-97110GT-PT SESSION BY LICENSED PT 5 14.250000 971.3600 68.1656
PHY-97110HM-PT SESSION BY PT ASST 11 27.500000 1582.9000 57.5600
PHY-97110HMGT-PT SESSION BY LICENSED PT ASST 4 8.750000 503.6500 57.5600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 9 47.750000 3370.2100 70.5803
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 14 56.000000 4003.0500 71.4830
Subtotal (Total Children Is Unduplicated) 777 4817.250000 246180.8800 51.1040
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Total 9284.750000 436892.5100 47.0548
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Number of Children (Unduplicated) With at Least One Service 1207
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Center 06
Flag Claims Units Chgs Paid
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R 1 0.500000 18.6000 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 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
10490 9283.250000 436836.7100 0.0000
Other 1 1.000000 37.2000 0.0000
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Total 10492 9284.750000 436892.5100 0.0000