CMS/EIP Fiscal Report Center: 54
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: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 865 3299.000000 122713.5000 37.1972
Subtotal (Total Children Is Unduplicated) 865 3299.000000 122713.5000 37.1972
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 4 8.000000 600.0000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 5 10.000000 750.0000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 4 8.000000 600.0000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 1 2.000000 150.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 2.000000 111.0000 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 11 22.000000 1221.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 5 7.500000 562.5000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 34 67.000000 5025.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 6 11.000000 825.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 50 97.000000 7275.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 8 15.000000 1125.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 25 49.500000 3712.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 18 33.000000 1831.5000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 98 191.000000 10600.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 21 41.000000 3075.0000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 54 114.000000 8550.0000 75.0000
Subtotal (Total Children Is Unduplicated) 188 678.000000 46014.0000 67.8673
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 325 1371.250000 68562.5000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 210 537.250000 26862.5000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 10 14.000000 1007.4400 71.9600
OCCT-97530GT-OT SESSION BY LICENSED OT 4 7.000000 503.7200 71.9600
OCCT-97530TL-OT SESSION BY LICENSED OT 59 243.500000 17522.2600 71.9600
OCCT-97530TLGT-OT SESSION BY LICENSED OT 25 67.000000 4821.3200 71.9600
PHY-97110-PT SESSION BY LICENSED PT 21 76.000000 5468.9600 71.9600
PHY-97110GT-PT SESSION BY LICENSED PT 1 2.000000 143.9200 71.9600
PHY-97110TL-PT SESSION BY LICENSED PT 48 209.000000 15039.6400 71.9600
PHY-97110TLGT-PT SESSION BY LICENSED PT 13 22.750000 1637.0900 71.9600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 23 100.000000 7196.0000 71.9600
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 5 6.000000 431.7600 71.9600
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 35 124.750000 8977.0100 71.9600
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 21 47.750000 3436.0900 71.9600
Subtotal (Total Children Is Unduplicated) 598 2828.250000 161610.2100 57.1414
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Total 6805.250000 330337.7100 48.5416
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Number of Children (Unduplicated) With at Least One Service 910
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Center 54
Flag Claims Units Chgs Paid
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R 15 17.750000 805.4200 0.0000
U 0 0.000000 0.0000 0.0000
B 986 913.250000 45206.5200 109.1600
P 4330 3916.500000 180403.4300 180221.3200
D 49 56.750000 3449.3000 0.0000
S 0 0.000000 0.0000 0.0000
H 5 5.000000 359.8000 0.0000
T 0 0.000000 0.0000 0.0000
1707 1820.500000 96580.8400 0.0000
Other 94 75.500000 3532.4000 329.9200
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Total 7186 6805.250000 330337.7100 180660.4000