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:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 976 3883.500000 144456.9000 37.1976
Subtotal (Total Children Is Unduplicated) 976 3883.500000 144456.9000 37.1976
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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 6 12.000000 900.0000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 4 8.000000 600.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 2.000000 150.0000 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 3 5.500000 305.2500 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 8 12.000000 900.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 56 103.500000 7762.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 11 18.000000 1350.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 79 149.500000 11212.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 13 21.500000 1612.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 48 89.000000 6675.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 22 40.000000 2220.0000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 143 275.000000 15262.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 27 52.500000 3937.5000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 64 136.000000 10200.0000 75.0000
Subtotal (Total Children Is Unduplicated) 274 956.500000 65058.7500 68.0175
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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 211 539.250000 26962.5000 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) 599 2830.250000 161710.2100 57.1364
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Total 7670.250000 371225.8600 48.3981
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Number of Children (Unduplicated) With at Least One Service 1022
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Center 54
Flag Claims Units Chgs Paid
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R 16 18.750000 842.6200 0.0000
U 0 0.000000 0.0000 0.0000
B 1083 1029.500000 50927.2200 109.1600
P 4842 4540.750000 208083.0300 207779.7200
D 52 62.750000 3899.3000 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
1766 1925.500000 103003.0900 0.0000
Other 105 88.000000 4110.8000 889.7200
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Total 7869 7670.250000 371225.8600 208778.6000