CMS/EIP Fiscal Report Center: 57
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 1076 4682.750000 174198.3000 37.2000
Subtotal (Total Children Is Unduplicated) 1076 4682.750000 174198.3000 37.2000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 10 18.500000 1387.5000 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 1 2.000000 150.0000 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-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 13 24.500000 1359.7500 55.5000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 195 345.000000 25875.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 67 118.000000 8850.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 47 75.000000 5625.0000 75.0000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 277 501.000000 27805.5000 55.5000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 34 58.500000 4387.5000 75.0000
OCTH-97165-OT EVAL LOW COMPLEXITY 1 1.000000 51.4100 51.4100
PSTF-97164-PT RE-EVAL EST PLAN CARE 3 3.000000 154.2300 51.4100
PSTH-97163-PT EVAL HIGH COMPLEXITY 1 1.000000 51.4100 51.4100
SPCH-92521-EVAL OF SPEECH FLUENCY 4 4.000000 205.6400 51.4100
Subtotal (Total Children Is Unduplicated) 334 1161.000000 76615.4400 65.9909
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EI Services,Class #03
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 1 13.000000 325.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 712 5123.000000 256150.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 45 212.500000 10625.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 7 38.000000 2734.4800 71.9600
OCCT-97530HM-OT SESSION BY OT ASST 3 17.000000 979.2000 57.6000
PHY-97110-PT SESSION BY LICENSED PT 4 38.000000 2734.4800 71.9600
PHY-97110HM-PT SESSION BY PT ASST 3 18.000000 1036.0800 57.5600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 8 61.000000 4389.5600 71.9600
Subtotal (Total Children Is Unduplicated) 746 5520.500000 278973.8000 50.5342
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Total 11364.250000 529787.5400 46.6188
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Number of Children (Unduplicated) With at Least One Service 1212
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Center 57
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 2569 3802.500000 160312.9500 334.3500
P 1195 1817.000000 82163.1300 81263.4800
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 9 17.500000 1205.2500 601.0500
1513 5506.500000 277894.3100 277894.3100
Other 192 220.750000 8211.9000 0.0000
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Total 5478 11364.250000 529787.5400 360093.1900