CMS/EIP Fiscal Report Center: 55
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 689 2347.250000 87261.9000 37.1762
Subtotal (Total Children Is Unduplicated) 689 2347.250000 87261.9000 37.1762
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 16 34.000000 2550.0000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 4 8.000000 600.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 3 6.000000 450.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 3 6.000000 450.0000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 1 2.000000 150.0000 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 9 18.000000 1038.0000 57.6667
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 139 282.000000 21150.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 13 26.000000 1950.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 20 40.000000 3000.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 3 6.000000 450.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 20 40.000000 3000.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 5 10.000000 750.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 81 160.000000 8880.0000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 14 28.000000 1554.0000 55.5000
OCTF-97168-OT RE-EVAL EST PLAN CARE 2 2.000000 102.8200 51.4100
OCTH-97167-OT EVAL HIGH COMPLEXITY 5 5.000000 257.0500 51.4100
PSTF-97164-PT RE-EVAL EST PLAN CARE 2 2.000000 102.8200 51.4100
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 7 7.000000 411.2800 58.7543
SPCH-92523TL-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 4 4.000000 205.6400 51.4100
Subtotal (Total Children Is Unduplicated) 228 688.000000 47201.6100 68.6070
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 164 822.250000 41112.5000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 9 42.000000 2100.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 49 214.500000 15435.4200 71.9600
OCCT-97530GT-OT SESSION BY LICENSED OT 1 1.000000 71.9600 71.9600
OCCT-97530HM-OT SESSION BY OT ASST 52 381.000000 21945.6000 57.6000
PHY-97110-PT SESSION BY LICENSED PT 27 125.000000 8995.0000 71.9600
PHY-97110GT-PT SESSION BY LICENSED PT 1 4.000000 287.8400 71.9600
PHY-97110HM-PT SESSION BY PT ASST 30 136.750000 7871.3300 57.5600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 102 546.250000 39308.1500 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 16 76.750000 5522.9300 71.9600
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 1 1.000000 71.9600 71.9600
Subtotal (Total Children Is Unduplicated) 375 2352.500000 142866.6100 60.7297
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Total 5387.750000 277330.1200 51.4742
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Number of Children (Unduplicated) With at Least One Service 729
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Center 55
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 1806 1833.000000 82203.0400 0.0000
P 1177 1145.500000 47371.5000 45595.5000
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
2304 2409.250000 147755.5800 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 5287 5387.750000 277330.1200 45595.5000