CMS/EIP Fiscal Report Center: 53
Services beginning 04/01/2023 ending 06/30/2023 Date of Report:07/25/2023 Page: 1
List order: No List
Payclass Filters:MED
Bill Flag Filter:RBPU
Eligibility Filter:All
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 694 1769.250000 65555.4000 37.0526
Subtotal (Total Children Is Unduplicated) 694 1769.250000 65555.4000 37.0526
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 3 4.500000 337.5000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 2 3.000000 225.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 5 7.500000 562.5000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 3 5.500000 412.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 2 3.500000 194.2500 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 8 13.500000 749.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 2 4.000000 300.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 70 117.000000 8662.5000 74.0385
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 6 7.500000 562.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 32 55.500000 4162.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 11 18.000000 1350.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 58 86.500000 6487.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 5 6.000000 333.0000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 88 146.000000 8103.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 2 4.000000 300.0000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 12 20.500000 1537.5000 75.0000
Subtotal (Total Children Is Unduplicated) 215 504.500000 34429.5000 68.2448
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 103 444.750000 22237.5000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 73 141.750000 7087.5000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 2 2.000000 143.9200 71.9600
OCCT-97530GT-OT SESSION BY LICENSED OT 3 2.500000 179.9000 71.9600
OCCT-97530TL-OT SESSION BY LICENSED OT 13 46.500000 3346.1400 71.9600
OCCT-97530TLGT-OT SESSION BY LICENSED OT 3 7.000000 503.7200 71.9600
PHY-97110-PT SESSION BY LICENSED PT 6 10.000000 719.6000 71.9600
PHY-97110TL-PT SESSION BY LICENSED PT 59 272.000000 19537.1400 71.8277
PHY-97110TLGT-PT SESSION BY LICENSED PT 14 17.500000 1259.3000 71.9600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 2 3.000000 215.8800 71.9600
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 3 5.000000 359.8000 71.9600
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 39 180.250000 12970.7900 71.9600
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 18 38.000000 2734.4800 71.9600
Subtotal (Total Children Is Unduplicated) 252 1170.250000 71295.6700 60.9235
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Total 3444.000000 171280.5700 49.7330
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Number of Children (Unduplicated) With at Least One Service 753
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Center 53
Flag Claims Units Chgs Paid
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R 115 114.500000 7888.4100 0.0000
U 0 0.000000 0.0000 0.0000
B 1313 1196.000000 58778.4900 0.0000
P 2320 2133.500000 104613.6700 104538.2100
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
0 0.000000 0.0000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 3748 3444.000000 171280.5700 104538.2100