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
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 696 1667.000000 61965.8000 37.1720
Subtotal (Total Children Is Unduplicated) 696 1667.000000 61965.8000 37.1720
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 2 4.000000 300.0000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 2 3.500000 262.5000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 3 5.500000 412.5000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 6 12.500000 937.5000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 1 1.500000 112.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 3 5.000000 277.5000 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 7 11.000000 610.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 8 13.500000 1012.5000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 71 127.500000 9562.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 7 13.500000 1012.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 47 84.500000 6337.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 8 13.500000 1012.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 42 69.000000 5175.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 29 52.500000 2913.7500 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 126 228.500000 12681.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 9 17.500000 1312.5000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 24 43.500000 3262.5000 75.0000
SPL-92526TL-TREATMENT OF SWALLOWING DYSFUNCTION 1 1.000000 52.9300 52.9300
Subtotal (Total Children Is Unduplicated) 226 707.500000 47248.9300 66.7829
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 310 1309.750000 65487.5000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 205 483.750000 24187.5000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 10 22.000000 1583.1200 71.9600
OCCT-97530GT-OT SESSION BY LICENSED OT 6 9.000000 647.6400 71.9600
OCCT-97530TL-OT SESSION BY LICENSED OT 36 100.500000 7231.9800 71.9600
OCCT-97530TLGT-OT SESSION BY LICENSED OT 22 36.000000 2590.5600 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) 496 2349.000000 129648.7800 55.1932
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Total 4723.500000 238863.5100 50.5692
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Number of Children (Unduplicated) With at Least One Service 851
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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 601 564.500000 29660.8800 0.0000
P 2538 2409.500000 120831.8700 120778.4900
D 43 43.000000 2459.3900 0.0000
S 160 120.500000 5461.9000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
1328 1399.500000 72322.7300 0.0000
Other 220 181.250000 7880.2400 0.0000
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Total 4896 4723.500000 238863.5100 120778.4900