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:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 739 2954.750000 109916.7000 37.2000
Subtotal (Total Children Is Unduplicated) 739 2954.750000 109916.7000 37.2000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 9 20.000000 1500.0000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 1 2.000000 150.0000 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 2 4.000000 222.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 220 437.273600 32795.5200 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 18 36.000000 2700.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 15 30.000000 2250.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 5 10.000000 750.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 38 75.000000 5625.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 2 4.000000 300.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 142 284.000000 15762.0000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 11 22.000000 1221.0000 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) 308 991.273600 66955.8900 67.5453
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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 60 270.000000 19429.2000 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) 402 3176.000000 188147.4500 59.2404
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Total 7122.023600 365020.0400 51.2523
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Number of Children (Unduplicated) With at Least One Service 786
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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 2729 2819.750000 125792.6500 0.0000
P 1059 1074.750000 45926.7000 45926.7000
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
3114 3223.750000 193036.5700 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 6905 7122.023600 365020.0400 45926.7000