CMS/EIP Fiscal Report Center: 53
Services beginning 01/01/2023 ending 03/31/2023 Date of Report:04/20/2023 Page: 1
List order: No List
Agency Filter:EIP DEI DEIP
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 617 1398.750000 52005.5000 37.1800
Subtotal (Total Children Is Unduplicated) 617 1398.750000 52005.5000 37.1800
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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 1 1.500000 112.5000 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 4 6.500000 487.5000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 1 1.500000 112.5000 75.0000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 4 6.000000 333.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 6 9.500000 712.5000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 54 97.500000 7312.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 2 4.000000 300.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 28 51.000000 3825.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 7 12.000000 900.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 29 50.000000 3750.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 1 2.000000 111.0000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 67 122.000000 6771.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 7 13.500000 1012.5000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 15 28.500000 2137.5000 75.0000
SPL-92526TL-TREATMENT OF SWALLOWING DYSFUNCTION 1 1.000000 52.9300 52.9300
Subtotal (Total Children Is Unduplicated) 159 412.000000 28342.9300 68.7935
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 115 447.250000 22362.5000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 81 153.750000 7687.5000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 5 6.000000 431.7600 71.9600
OCCT-97530GT-OT SESSION BY LICENSED OT 4 7.000000 503.7200 71.9600
OCCT-97530TL-OT SESSION BY LICENSED OT 29 84.500000 6080.6200 71.9600
OCCT-97530TLGT-OT SESSION BY LICENSED OT 17 28.000000 2014.8800 71.9600
PHY-97110-PT SESSION BY LICENSED PT 2 2.000000 143.9200 71.9600
PHY-97110TL-PT SESSION BY LICENSED PT 44 213.250000 15345.4700 71.9600
PHY-97110TLGT-PT SESSION BY LICENSED PT 10 9.000000 647.6400 71.9600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 7 14.000000 1007.4400 71.9600
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 6 11.000000 791.5600 71.9600
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 34 98.500000 7088.0600 71.9600
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 19 40.250000 2896.3900 71.9600
Subtotal (Total Children Is Unduplicated) 256 1114.500000 67001.4600 60.1180
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Total 2925.250000 147349.8900 50.3717
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Number of Children (Unduplicated) With at Least One Service 695
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Center 53
Flag Claims Units Chgs Paid
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R 6 5.250000 246.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 519 488.000000 25917.9300 0.0000
P 2285 2136.750000 107902.1700 107851.1900
D 37 33.500000 1863.8900 0.0000
S 137 102.250000 4612.9000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
2 3.000000 146.3600 0.0000
Other 194 156.500000 6660.1400 0.0000
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Total 3180 2925.250000 147349.8900 107851.1900