CMS/EIP Fiscal Report Center: 09
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:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 1148 4019.250000 149497.5000 37.1954
Subtotal (Total Children Is Unduplicated) 1148 4019.250000 149497.5000 37.1954
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 2 4.000000 300.0000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 3 6.000000 450.0000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 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 3 6.000000 333.0000 55.5000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 148 280.000000 21000.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 88 170.500000 12787.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 2 4.000000 300.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 51 94.500000 7087.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 1 2.000000 111.0000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 198 376.500000 20895.7500 55.5000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 29 56.500000 4237.5000 75.0000
OCTH-97166GT-OT EVAL MODERATE COMPLEXITY 1 1.000000 51.4100 51.4100
OCTH-97166TLGT-OT EVAL MODERATE COMPLEXITY 1 1.000000 51.4100 51.4100
SPCH-92523TLGT-EVAL OF SPCH SOUND PROD; EVAL LANG COM 4 4.000000 205.6400 51.4100
SPL-92526-TREATMENT OF SWALLOWING DYSFUNCTION 1 4.000000 211.7200 52.9300
Subtotal (Total Children Is Unduplicated) 270 1014.000000 68322.4300 67.3791
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 705 4736.000000 236564.2400 49.9502
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 77 250.000000 12500.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 39 244.250000 17576.2300 71.9600
OCCT-97530TLGT-OT SESSION BY LICENSED OT 4 20.000000 1439.2000 71.9600
PHY-97110-PT SESSION BY LICENSED PT 29 190.250000 13690.3900 71.9600
PHY-97110GT-PT SESSION BY LICENSED PT 2 10.000000 719.6000 71.9600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 66 484.000000 34828.6400 71.9600
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 3 3.000000 215.8800 71.9600
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 1 2.000000 143.9200 71.9600
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 21 76.000000 5468.9600 71.9600
Subtotal (Total Children Is Unduplicated) 826 6015.500000 323147.0600 53.7191
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Total 11048.750000 540966.9900 48.9618
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Number of Children (Unduplicated) With at Least One Service 1294
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Center 09
Flag Claims Units Chgs Paid
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R 196 195.750000 7548.9400 0.0000
U 0 0.000000 0.0000 0.0000
B 4271 4552.000000 186160.9300 0.0000
P 0 0.000000 0.0000 0.0000
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 0 0.000000 0.0000 0.0000
1772 5979.500000 325029.0200 0.0000
Other 166 321.500000 22228.1000 0.0000
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Total 6405 11048.750000 540966.9900 0.0000