CMS/EIP Fiscal Report Center: 03
Services beginning 07/01/2022 ending 06/30/2023 Date of Report:07/25/2023 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 1589 7481.750000 278001.9500 37.1573
Subtotal (Total Children Is Unduplicated) 1589 7481.750000 278001.9500 37.1573
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 5 8.500000 637.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 9 15.500000 860.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 5 8.500000 637.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 14 24.000000 1800.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 1 1.000000 75.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 219 418.500000 23226.7500 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 8 14.000000 777.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 45 72.000000 5400.0000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 2.000000 150.0000 75.0000
SCREEN-T1023-SCREENING 21 22.000000 1100.0000 50.0000
SPL-92526TL-TREATMENT OF SWALLOWING DYSFUNCTION 1 1.000000 52.5700 52.5700
Subtotal (Total Children Is Unduplicated) 300 587.000000 34716.5700 59.1424
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 25 147.000000 7325.0000 49.8299
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 27 24.750000 1237.5000 50.0000
OCCT-97530GT-OT SESSION BY LICENSED OT 1 1.000000 71.4400 71.4400
OCCT-97530TL-OT SESSION BY LICENSED OT 1 1.000000 71.4400 71.4400
OCCT-97530TLGT-OT SESSION BY LICENSED OT 2 3.000000 214.3200 71.4400
PHY-97110-PT SESSION BY LICENSED PT 3 3.000000 214.3200 71.4400
PHY-97110TL-PT SESSION BY LICENSED PT 1 1.000000 71.4400 71.4400
PHY-97110TLGT-PT SESSION BY LICENSED PT 1 0.750000 53.5800 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 1 1.000000 71.4400 71.4400
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 1 1.000000 71.4400 71.4400
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 2 2.000000 142.8800 71.4400
Subtotal (Total Children Is Unduplicated) 60 185.500000 9544.8000 51.4544
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Total 8254.250000 322263.3200 39.0421
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Number of Children (Unduplicated) With at Least One Service 1604
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Center 03
Flag Claims Units Chgs Paid
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R 107 145.500000 5412.6000 0.0000
U 0 0.000000 0.0000 0.0000
B 6184 4286.000000 165996.2400 0.0000
P 2910 2029.750000 80467.5500 80281.4800
D 82 83.250000 3621.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 1 2.000000 150.0000 150.0000
T 0 0.000000 0.0000 0.0000
1865 1448.750000 56702.2300 0.0000
Other 263 259.000000 9913.7000 0.0000
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Total 11412 8254.250000 322263.3200 80431.4800