CMS/EIP Fiscal Report Center: 10
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 2345 7971.250000 296381.7000 37.1813
Subtotal (Total Children Is Unduplicated) 2345 7971.250000 296381.7000 37.1813
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 7 13.000000 975.0000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 7 12.500000 937.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 2.000000 150.0000 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-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 4 8.000000 600.0000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 3 4.500000 337.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 4 7.000000 388.5000 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 8 15.000000 832.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 103 187.000000 13950.0000 74.5989
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 132 256.000000 19200.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 37 67.500000 5062.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 62 115.000000 8625.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 52 89.000000 6675.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 28 49.000000 3675.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 139 253.500000 14041.5000 55.3905
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 164 313.000000 17371.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 68 108.500000 8100.0000 74.6544
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 19 36.500000 2737.5000 75.0000
OCTH-97165-OT EVAL LOW COMPLEXITY 9 7.000000 359.8700 51.4100
OCTH-97166-OT EVAL MODERATE COMPLEXITY 12 12.000000 616.9200 51.4100
PSTH-97161-PT EVAL LOW COMPLEXITY 6 4.500000 231.3450 51.4100
PSTH-97162-PT EVAL MODERATE COMPLEXITY 2 2.000000 102.8200 51.4100
SPCH-92521-EVAL OF SPEECH FLUENCY 20 19.250000 989.6425 51.4100
SPCH-92521GT-EVAL OF SPEECH FLUENCY 1 1.000000 51.4100 51.4100
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 3 3.000000 154.2300 51.4100
Subtotal (Total Children Is Unduplicated) 444 1591.250000 106577.7375 66.9774
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 563 4552.250000 227612.5000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 451 2633.750000 131540.5000 49.9442
OCCT-97530-OT SESSION BY LICENSED OT 178 952.250000 68523.9100 71.9600
OCCT-97530GT-OT SESSION BY LICENSED OT 30 85.750000 6170.5700 71.9600
OCCT-97530HM-OT SESSION BY OT ASST 50 193.500000 11145.6000 57.6000
OCCT-97530HMGT-OT SESSION BY OT ASST 3 4.500000 259.2000 57.6000
PHY-97110-PT SESSION BY LICENSED PT 244 1004.000000 72247.8400 71.9600
PHY-97110GT-PT SESSION BY LICENSED PT 8 19.000000 1367.2400 71.9600
PHY-97110HM-PT SESSION BY PT ASST 2 2.000000 115.1200 57.5600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 271 1638.750000 117924.4500 71.9600
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 31 122.750000 8833.0900 71.9600
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 1 3.750000 216.0000 57.6000
SPL-92507HMGT-SPL THERAPY SESSION BY SLP ASST 1 9.750000 561.6000 57.6000
Subtotal (Total Children Is Unduplicated) 1285 11222.00000 646517.6200 57.6116
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Total 20784.500000 1049477.0575 50.4933
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Number of Children (Unduplicated) With at Least One Service 2518
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Center 10
Flag Claims Units Chgs Paid
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R 8 6.750000 251.1000 0.0000
U 0 0.000000 0.0000 0.0000
B 10149 8829.250000 370133.7000 0.0000
P 2 5.000000 359.8000 40.0000
D 183 220.500000 13131.8600 0.0000
S 3 7.000000 415.8800 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
3932 11418.750000 654127.0175 0.0000
Other 394 297.250000 11057.7000 0.0000
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Total 14671 20784.500000 1049477.0575 40.0000