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
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 662 1563.750000 57929.4500 37.0452
Subtotal (Total Children Is Unduplicated) 662 1563.750000 57929.4500 37.0452
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 3 6.500000 487.5000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 3 4.500000 337.5000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 3 4.500000 337.5000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 1 2.000000 150.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 1.500000 83.2500 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 10 20.000000 1110.0000 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 56 99.000000 7312.5000 73.8636
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 3 4.000000 300.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 36 64.000000 4800.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 7 12.000000 900.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 42 70.000000 5250.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 17 29.500000 1637.2500 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 98 170.000000 9435.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 4 8.000000 600.0000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 12 21.000000 1575.0000 75.0000
Subtotal (Total Children Is Unduplicated) 168 520.500000 34615.5000 66.5043
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 315 1377.750000 68887.5000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 237 523.250000 26162.5000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 28 88.000000 6332.4800 71.9600
OCCT-97530GT-OT SESSION BY LICENSED OT 14 25.500000 1813.0200 71.0988
OCCT-97530TL-OT SESSION BY LICENSED OT 31 93.500000 6728.2600 71.9600
OCCT-97530TLGT-OT SESSION BY LICENSED OT 5 10.000000 719.6000 71.9600
PHY-97110-PT SESSION BY LICENSED PT 7 11.000000 791.5600 71.9600
PHY-97110TL-PT SESSION BY LICENSED PT 61 276.000000 19824.9800 71.8296
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 42 193.250000 13906.2700 71.9600
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 19 40.500000 2914.3800 71.9600
Subtotal (Total Children Is Unduplicated) 539 2664.250000 149915.5300 56.2693
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Total 4748.500000 242460.4800 51.0604
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Number of Children (Unduplicated) With at Least One Service 811
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Center 53
Flag Claims Units Chgs Paid
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R 114 113.000000 7775.9100 0.0000
U 0 0.000000 0.0000 0.0000
B 1174 1043.500000 51417.9900 0.0000
P 2051 1850.000000 91564.5200 91489.0600
D 13 10.500000 520.4800 0.0000
S 99 95.750000 4774.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
1457 1500.750000 79560.4000 0.0000
Other 166 135.000000 6847.1800 59.2500
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Total 5074 4748.500000 242460.4800 91548.3100