CMS/EIP Fiscal Report Center: 53
Services beginning 10/01/2023 ending 12/31/2023 Date of Report:01/14/2024 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 591 1463.000000 54303.6000 37.1180
Subtotal (Total Children Is Unduplicated) 591 1463.000000 54303.6000 37.1180
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
AACIS-92597TL-AAC INTIAL EVAL BY LICENSED SLP 1 1.000000 103.3600 103.3600
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 9 16.000000 1200.0000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 4 7.000000 525.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 3 6.000000 450.0000 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 5 8.000000 444.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 3 6.000000 450.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 41 71.500000 5362.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 2 3.000000 225.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 23 43.500000 3262.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 1 1.500000 112.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 36 60.000000 4500.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 2 4.000000 222.0000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 76 129.500000 7131.7500 55.0714
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 5 10.000000 750.0000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 15 27.000000 2025.0000 75.0000
SPCH-92521TLGT-EVAL OF SPEECH FLUENCY 1 1.000000 51.4100 51.4100
SPCH-92610TL-EVAL OF ORAL,PHARYNGEAL SWALLOWING FUNC 1 1.000000 51.4100 51.4100
SPL-92526TL-TREATMENT OF SWALLOWING DYSFUNCTION 1 5.000000 257.0500 51.4100
Subtotal (Total Children Is Unduplicated) 170 409.000000 27723.4800 67.7836
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 105 353.250000 17662.5000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 36 66.500000 3325.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 1 3.000000 215.8800 71.9600
OCCT-97530GT-OT SESSION BY LICENSED OT 1 1.000000 71.9600 71.9600
OCCT-97530TL-OT SESSION BY LICENSED OT 24 77.500000 5576.9000 71.9600
OCCT-97530TLGT-OT SESSION BY LICENSED OT 16 45.500000 3238.2000 71.1692
PHY-97110-PT SESSION BY LICENSED PT 1 6.000000 431.7600 71.9600
PHY-97110TL-PT SESSION BY LICENSED PT 43 224.000000 16119.0400 71.9600
PHY-97110TLGT-PT SESSION BY LICENSED PT 16 18.000000 1295.2800 71.9600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 4 3.250000 233.8700 71.9600
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 1 2.000000 143.9200 71.9600
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 51 147.000000 10578.1200 71.9600
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 21 47.750000 3436.0900 71.9600
Subtotal (Total Children Is Unduplicated) 231 994.750000 62328.5200 62.6575
-----------------------------------------------------------------------------------------------------------------------
Total 2866.750000 144355.6000 50.3551
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 676
-----------------------------------------------------------------------------------------------------------------------
Center 53
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 27 23.250000 903.3000 0.0000
U 0 0.000000 0.0000 0.0000
B 486 451.500000 24329.7000 0.0000
P 2528 2392.000000 119122.6000 119094.4000
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
---------------------------------------------------------
Total 3041 2866.750000 144355.6000 119094.4000