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:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 1188 3845.000000 143014.3000 37.1949
Subtotal (Total Children Is Unduplicated) 1188 3845.000000 143014.3000 37.1949
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 2 4.000000 300.0000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 2 3.500000 262.5000 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 5 9.500000 527.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 16 29.000000 2175.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 120 210.500000 15787.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 9 15.500000 1162.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 107 187.000000 14025.0000 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 57 102.500000 7687.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 16 29.000000 1609.5000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 171 315.500000 17510.2500 55.5000
MED-99205-OUTPATIENT VISIT, NEW, 60 MINS 1 1.000000 142.2300 142.2300
Subtotal (Total Children Is Unduplicated) 257 917.000000 61939.2300 67.5455
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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 9579.250000 451134.4100 47.0950
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Number of Children (Unduplicated) With at Least One Service 1257
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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
10744 9577.750000 451078.6100 0.0000
Other 1 1.000000 37.2000 0.0000
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Total 10746 9579.250000 451134.4100 0.0000