CMS/EIP Fiscal Report Center: 52
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 529 1382.750000 51363.9000 37.1462
Subtotal (Total Children Is Unduplicated) 529 1382.750000 51363.9000 37.1462
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 10 18.500000 1387.5000 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 2 4.000000 300.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 2.000000 150.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 9 18.000000 999.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 105 211.000000 15825.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 4 8.000000 600.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 52 104.000000 7800.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 12 24.000000 1800.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 129 257.000000 14263.5000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 1 2.000000 111.0000 55.5000
PSTH-97163TLGT-PT EVAL HIGH COMPLEXITY 1 1.000000 51.4100 51.4100
SCREEN-T1023-SCREENING 26 26.000000 1300.0000 50.0000
SPCH-92523TL-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 3 3.000000 154.2300 51.4100
SPL-92526TL-TREATMENT OF SWALLOWING DYSFUNCTION 7 29.000000 1534.9700 52.9300
Subtotal (Total Children Is Unduplicated) 198 711.500000 46576.6100 65.4626
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 249 1211.500000 60575.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 5 4.750000 237.5000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 3 5.000000 359.8000 71.9600
OCCT-97530HM-OT SESSION BY OT ASST 1 4.000000 230.4000 57.6000
OCCT-97530TL-OT SESSION BY LICENSED OT 17 76.500000 5504.9400 71.9600
OCCT-97530TLGT-OT SESSION BY LICENSED OT 1 1.000000 71.9600 71.9600
OCCT-97530TLHM-OT SESSION BY OT ASST 9 39.000000 2246.4000 57.6000
PHY-97110HM-PT SESSION BY PT ASST 2 3.000000 172.6800 57.5600
PHY-97110TL-PT SESSION BY LICENSED PT 25 82.000000 5900.7200 71.9600
PHY-97110TLHM-PT SESSION BY PT ASST 8 38.750000 2230.4500 57.5600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 2 2.000000 124.9000 62.4500
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 59 256.250000 18401.7100 71.8116
Subtotal (Total Children Is Unduplicated) 328 1723.750000 96056.4600 55.7253
-----------------------------------------------------------------------------------------------------------------------
Total 3818.000000 193996.9700 50.8111
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 623
-----------------------------------------------------------------------------------------------------------------------
Center 52
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 19 20.000000 883.0400 0.0000
U 0 0.000000 0.0000 0.0000
B 875 908.250000 46050.9400 0.0000
P 1619 1696.000000 78576.5000 78577.1500
D 1 1.000000 50.0000 0.0000
S 158 133.000000 6263.1500 652.3000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
518 1059.750000 62173.3400 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 3190 3818.000000 193996.9700 79229.4500