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:TPIN
Eligibility Filter:Part C (excluding not eligible)
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
CASE-CASE-NON-TCM CASE MANAGEMENT 1 0.500000 18.6000 37.2000
TCM-T1017TL-TARGETED CASE MANAGEMENT 5 3.750000 139.5000 37.2000
Subtotal (Total Children Is Unduplicated) 6 4.250000 158.1000 37.2000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 2 3.500000 262.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 1.500000 112.5000 75.0000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 1 1.500000 83.2500 55.5000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 9 16.000000 1200.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 6 10.500000 787.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 1 1.500000 112.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 8 15.000000 1125.0000 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 17 31.500000 1748.2500 55.5000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 3 5.000000 312.5000 62.5000
Subtotal (Total Children Is Unduplicated) 37 90.000000 6005.0000 66.7222
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EI Services,Class #03
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 1 1.000000 0.0000 0.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 28 106.250000 5312.5000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 10 19.000000 950.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 13 74.250000 5343.0300 71.9600
OCCT-97530GT-OT SESSION BY LICENSED OT 1 3.000000 215.8800 71.9600
PHY-97110-PT SESSION BY LICENSED PT 18 82.250000 5918.7100 71.9600
PHY-97110GT-PT SESSION BY LICENSED PT 5 11.000000 791.5600 71.9600
PHY-97110TL-PT SESSION BY LICENSED PT 1 6.000000 431.7600 71.9600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 41 157.750000 11351.6900 71.9600
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 18 24.750000 1781.0100 71.9600
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 2 5.000000 359.8000 71.9600
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 1 2.500000 179.9000 71.9600
Subtotal (Total Children Is Unduplicated) 101 492.750000 32635.8400 66.2320
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Total 587.000000 38798.9400 66.0970
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Number of Children (Unduplicated) With at Least One Service 127
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Center 53
Flag Claims Units Chgs Paid
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R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 0 0.000000 0.0000 0.0000
P 1 1.000000 71.9600 72.0000
D 27 23.250000 1572.9000 0.0000
S 1 1.500000 150.0000 0.0000
H 42 42.000000 2821.6300 0.0000
T 0 0.000000 0.0000 0.0000
485 517.250000 34082.4500 0.0000
Other 2 2.000000 100.0000 0.0000
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Total 558 587.000000 38798.9400 72.0000