CMS/EIP Fiscal Report Center: 06
Services beginning 10/01/2023 ending 12/31/2023 Date of Report:01/14/2024 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 1119 3505.000000 130386.0000 37.2000
Subtotal (Total Children Is Unduplicated) 1119 3505.000000 130386.0000 37.2000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 2 4.000000 300.0000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 4 7.500000 562.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 2 4.000000 222.0000 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 4 7.500000 416.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 39 69.500000 5212.5000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 112 209.500000 15683.2500 74.8604
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 26 48.500000 3637.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 46 87.500000 6562.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 11 20.500000 1537.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 12 22.500000 1687.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 37 68.000000 3774.0000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 101 187.000000 10417.5000 55.7086
Subtotal (Total Children Is Unduplicated) 199 736.000000 50013.0000 67.9524
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 575 3694.250000 185162.5000 50.1218
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 112 421.000000 21050.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 5 11.500000 827.5400 71.9600
OCCT-97530GT-OT SESSION BY LICENSED OT 3 19.000000 1367.2400 71.9600
OCCT-97530HM-OT SESSION BY OT ASST 3 7.500000 489.6000 65.2800
OCCT-97530HMGT-OT SESSION BY OT ASST 5 16.750000 935.9800 55.8794
PHY-97110-PT SESSION BY LICENSED PT 10 81.000000 5784.4800 71.4133
PHY-97110HM-PT SESSION BY PT ASST 5 12.750000 726.3300 56.9671
PHY-97110HMGT-PT SESSION BY LICENSED PT ASST 4 7.000000 402.9200 57.5600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 9 47.000000 3382.1200 71.9600
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 10 47.000000 3382.1200 71.9600
Subtotal (Total Children Is Unduplicated) 656 4364.750000 223510.8300 51.2082
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Total 8605.750000 403909.8300 46.9349
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Number of Children (Unduplicated) With at Least One Service 1240
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Center 06
Flag Claims Units Chgs Paid
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R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 0 0.000000 0.0000 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
9393 8605.750000 403909.8300 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 9393 8605.750000 403909.8300 0.0000