CMS/EIP Fiscal Report Center: 04
Services beginning 04/01/2023 ending 06/30/2023 Date of Report:07/25/2023 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 1129 4746.000000 176551.2000 37.2000
Subtotal (Total Children Is Unduplicated) 1129 4746.000000 176551.2000 37.2000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 10 12.500000 937.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 1.000000 75.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 5 5.500000 412.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 11 15.500000 860.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 140 174.500000 13087.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 8 9.000000 675.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 182 249.500000 13847.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 120 179.000000 13425.0000 75.0000
OCTH-97165-OT EVAL LOW COMPLEXITY 3 3.000000 154.2300 51.4100
PSTH-97161-PT EVAL LOW COMPLEXITY 3 3.000000 154.2300 51.4100
PSTH-97163-PT EVAL HIGH COMPLEXITY 5 5.000000 257.0500 51.4100
SPCH-92521-EVAL OF SPEECH FLUENCY 1 1.000000 51.4100 51.4100
Subtotal (Total Children Is Unduplicated) 226 658.500000 43936.9200 66.7227
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 842 8316.000000 415530.0000 49.9675
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 76 285.000000 14250.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 9 34.000000 2446.6400 71.9600
OCCT-97530HM-OT SESSION BY OT ASST 10 60.500000 3484.8000 57.6000
PHY-97110-PT SESSION BY LICENSED PT 5 21.000000 1489.2000 70.9143
PHY-97110HM-PT SESSION BY PT ASST 13 72.250000 4128.4700 57.1415
PHY-97110TL-PT SESSION BY LICENSED PT 1 8.000000 575.6800 71.9600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 4 15.000000 1079.4000 71.9600
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 2 1.000000 71.9600 71.9600
Subtotal (Total Children Is Unduplicated) 906 8812.750000 443056.1500 50.2744
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Total 14217.250000 663544.2700 46.6718
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Number of Children (Unduplicated) With at Least One Service 1397
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Center 04
Flag Claims Units Chgs Paid
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R 203 316.500000 12306.1500 0.0000
U 0 0.000000 0.0000 0.0000
B 1901 3079.250000 119555.4000 0.0000
P 714 1186.250000 46953.5000 46565.2000
D 204 326.250000 12453.5900 0.0000
S 3 4.250000 158.1000 0.0000
H 2275 8797.500000 442183.7600 0.0000
T 0 0.000000 0.0000 0.0000
372 507.250000 29933.7700 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 5672 14217.250000 663544.2700 46565.2000