CMS/EIP Fiscal Report Center: 04
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 2695 20195.25000 750152.2000 37.1450
Subtotal (Total Children Is Unduplicated) 2695 20195.25000 750152.2000 37.1450
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 18 22.000000 1650.0000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 9 9.500000 712.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 4 4.500000 337.5000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 13 15.000000 1125.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 7 7.500000 552.7500 73.7000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 8 7.500000 562.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 20 26.000000 1443.0000 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 24 27.000000 1498.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 277 325.000000 24375.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 264 287.000000 21525.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 74 78.000000 5850.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 242 257.500000 19312.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 432 545.500000 30275.2500 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 611 743.000000 41236.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 333 412.500000 30937.5000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 170 197.000000 14775.0000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 22 22.000000 1649.6800 74.9855
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 1 1.000000 31.1700 31.1700
OCTF-97168-OT RE-EVAL EST PLAN CARE 1 1.000000 51.4100 51.4100
OCTH-97165-OT EVAL LOW COMPLEXITY 20 24.000000 1230.6000 51.2750
OCTH-97165TL-OT EVAL LOW COMPLEXITY 4 4.000000 205.6400 51.4100
OCTH-97167-OT EVAL HIGH COMPLEXITY 4 7.000000 359.5100 51.3586
PSTF-97164-PT RE-EVAL EST PLAN CARE 1 1.000000 51.4100 51.4100
PSTH-97161-PT EVAL LOW COMPLEXITY 6 7.000000 359.8700 51.4100
PSTH-97161TL-PT EVAL LOW COMPLEXITY 2 2.000000 102.8200 51.4100
PSTH-97162-PT EVAL MODERATE COMPLEXITY 2 2.000000 102.4600 51.2300
PSTH-97162GT-PT EVAL MODERATE COMPLEXITY 1 1.000000 51.0500 51.0500
PSTH-97162TL-PT EVAL MODERATE COMPLEXITY 1 1.000000 51.4100 51.4100
PSTH-97163-PT EVAL HIGH COMPLEXITY 9 14.000000 719.3800 51.3843
PSTH-97163GT-PT EVAL HIGH COMPLEXITY 2 6.000000 308.4600 51.4100
PSTH-97163TL-PT EVAL HIGH COMPLEXITY 1 1.000000 51.4100 51.4100
SPCH-92521-EVAL OF SPEECH FLUENCY 8 8.000000 409.8400 51.2300
SPCH-92521TL-EVAL OF SPEECH FLUENCY 1 1.000000 51.4100 51.4100
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 3 3.000000 153.8700 51.2900
SPCH-92610-EVAL OF ORAL,PHARYNGEAL SWALLOWING FUNC 1 2.000000 96.2700 48.1350
Subtotal (Total Children Is Unduplicated) 1175 3072.500000 202206.1700 65.8116
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1519 31094.00000 1553580.0000 49.9640
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 297 1716.000000 85750.0000 49.9709
OCCT-97530-OT SESSION BY LICENSED OT 31 316.500000 22648.5200 71.5593
OCCT-97530HM-OT SESSION BY OT ASST 25 238.500000 13723.2000 57.5396
OCCT-97530TL-OT SESSION BY LICENSED OT 4 7.500000 539.7000 71.9600
PHY-97110-PT SESSION BY LICENSED PT 14 102.000000 7317.4400 71.7396
PHY-97110HM-PT SESSION BY PT ASST 36 340.750000 19536.9800 57.3352
PHY-97110HMGT-PT SESSION BY LICENSED PT ASST 1 0.500000 28.5800 57.1600
PHY-97110TL-PT SESSION BY LICENSED PT 4 16.000000 1151.3600 71.9600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 17 93.750000 6736.7600 71.8588
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 2 1.000000 71.9600 71.9600
SPL-92508HA-GROUP SPL SESSION PER CHILD 1 0.500000 6.9400 13.8800
Subtotal (Total Children Is Unduplicated) 1657 33927.00000 1711091.4400 50.4345
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Total 57194.750000 2663449.8100 46.5681
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Number of Children (Unduplicated) With at Least One Service 2811
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Center 04
Flag Claims Units Chgs Paid
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R 210 326.500000 12902.5500 0.0000
U 0 0.000000 0.0000 0.0000
B 5978 8978.500000 357464.0500 0.0000
P 7138 11391.000000 455718.6000 450651.3300
D 982 1409.750000 54457.0500 27.8600
S 5 6.500000 241.5000 0.0000
H 9036 33881.000000 1707708.0300 210.0000
T 1 3.000000 111.0000 0.0000
999 1186.250000 74327.3300 0.0000
Other 4 12.250000 519.7000 0.0000
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Total 24353 57194.750000 2663449.8100 450889.1900