CMS/EIP Fiscal Report Center: 53
Services beginning 07/01/2023 ending 09/30/2023 Date of Report:10/10/2023 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 652 1512.250000 56032.4500 37.0524
Subtotal (Total Children Is Unduplicated) 652 1512.250000 56032.4500 37.0524
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 2 3.000000 225.0000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 2 3.500000 262.5000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 4 7.500000 562.5000 75.0000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 7 13.000000 721.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 2 3.500000 262.5000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 65 110.500000 8287.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 53 95.500000 7162.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 25 40.500000 3037.5000 75.0000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 105 181.000000 10045.5000 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 19 38.000000 2850.0000 75.0000
SPL-92526TL-TREATMENT OF SWALLOWING DYSFUNCTION 1 10.000000 514.1000 51.4100
Subtotal (Total Children Is Unduplicated) 184 510.000000 34231.1000 67.1198
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 259 888.250000 44412.5000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 152 294.500000 14725.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 37 100.000000 7196.0000 71.9600
OCCT-97530GT-OT SESSION BY LICENSED OT 13 21.000000 1511.1600 71.9600
OCCT-97530TL-OT SESSION BY LICENSED OT 36 93.500000 6728.2600 71.9600
OCCT-97530TLGT-OT SESSION BY LICENSED OT 13 27.000000 1942.9200 71.9600
PHY-97110-PT SESSION BY LICENSED PT 3 17.000000 1223.3200 71.9600
PHY-97110GT-PT SESSION BY LICENSED PT 3 3.000000 215.8800 71.9600
PHY-97110TL-PT SESSION BY LICENSED PT 50 270.500000 19465.1800 71.9600
PHY-97110TLGT-PT SESSION BY LICENSED PT 12 12.750000 917.4900 71.9600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 3 3.000000 215.8800 71.9600
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 6 7.500000 539.7000 71.9600
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 47 119.500000 8599.2200 71.9600
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 33 58.750000 4227.6500 71.9600
Subtotal (Total Children Is Unduplicated) 477 1916.250000 111920.1600 58.4058
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Total 3938.500000 202183.7100 51.3352
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Number of Children (Unduplicated) With at Least One Service 822
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Center 53
Flag Claims Units Chgs Paid
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R 80 64.750000 3757.9500 0.0000
U 0 0.000000 0.0000 0.0000
B 736 671.250000 34949.1800 0.0000
P 2229 2055.500000 100648.0900 100632.5300
D 4 3.000000 146.3600 0.0000
S 32 33.250000 2333.3200 0.0000
H 3 3.000000 215.8800 0.0000
T 0 0.000000 0.0000 0.0000
879 914.750000 49793.2100 0.0000
Other 222 193.000000 10339.7200 0.0000
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Total 4185 3938.500000 202183.7100 100632.5300