CMS/EIP Fiscal Report Center: 55
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 628 2625.500000 97668.6000 37.2000
Subtotal (Total Children Is Unduplicated) 628 2625.500000 97668.6000 37.2000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 6 14.000000 1050.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 3 6.000000 450.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH 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
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 126 250.273600 18770.5200 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 9 18.000000 1350.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 9 18.000000 1350.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 4 8.000000 600.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 24 48.000000 3600.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 76 152.000000 8436.0000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 7 14.000000 777.0000 55.5000
OCTF-97168-OT RE-EVAL EST PLAN CARE 10 10.000000 514.1000 51.4100
OCTH-97165-OT EVAL LOW COMPLEXITY 1 3.000000 154.2300 51.4100
OCTH-97166-OT EVAL MODERATE COMPLEXITY 2 2.000000 102.8200 51.4100
OCTH-97166TLGT-OT EVAL MODERATE COMPLEXITY 1 1.000000 51.4100 51.4100
OCTH-97167-OT EVAL HIGH COMPLEXITY 14 17.000000 873.9700 51.4100
PSTF-97164-PT RE-EVAL EST PLAN CARE 3 6.000000 308.4600 51.4100
PSTH-97163-PT EVAL HIGH COMPLEXITY 4 4.000000 205.6400 51.4100
SPCH-92521-EVAL OF SPEECH FLUENCY 1 1.000000 51.4100 51.4100
SPCH-92521TL-EVAL OF SPEECH FLUENCY 1 1.000000 51.4100 51.4100
SPCH-92521TLGT-EVAL OF SPEECH FLUENCY 1 1.000000 51.4100 51.4100
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 11 11.000000 565.5100 51.4100
Subtotal (Total Children Is Unduplicated) 196 593.273600 39874.8900 67.2116
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 184 1233.500000 61675.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 13 65.500000 3275.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 59 269.000000 19357.2400 71.9600
OCCT-97530GT-OT SESSION BY LICENSED OT 1 2.000000 143.9200 71.9600
OCCT-97530HM-OT SESSION BY OT ASST 73 549.250000 31636.8000 57.6000
OCCT-97530HMGT-OT SESSION BY OT ASST 1 6.000000 345.6000 57.6000
OCCT-97530TLHM-OT SESSION BY OT ASST 1 18.000000 1036.8000 57.6000
PHY-97110-PT SESSION BY LICENSED PT 27 170.000000 12233.2000 71.9600
PHY-97110GT-PT SESSION BY LICENSED PT 1 2.000000 143.9200 71.9600
PHY-97110HM-PT SESSION BY PT ASST 40 239.750000 13800.0100 57.5600
PHY-97110HMGT-PT SESSION BY LICENSED PT ASST 1 6.000000 345.3600 57.5600
PHY-97110TL-PT SESSION BY LICENSED PT 1 7.000000 503.7200 71.9600
PHY-97110TLHM-PT SESSION BY PT ASST 1 7.000000 402.9200 57.5600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 90 528.000000 37994.8800 71.9600
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 2 9.500000 683.6200 71.9600
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 9 60.000000 4317.6000 71.9600
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 1 2.500000 179.9000 71.9600
Subtotal (Total Children Is Unduplicated) 401 3175.000000 188075.4900 59.2364
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Total 6393.773600 325618.9800 50.9275
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Number of Children (Unduplicated) With at Least One Service 665
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Center 55
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 2488 2371.250000 102124.4500 0.0000
P 952 887.000000 36310.8000 36310.8000
D 0 0.000000 0.0000 0.0000
S 2 3.273600 245.5200 0.0000
H 1 0.500000 18.6000 0.0000
T 0 0.000000 0.0000 0.0000
3067 3131.750000 186919.6100 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 6510 6393.773600 325618.9800 36310.8000