CMS/EIP Fiscal Report Center: 52
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 1065 4999.250000 185251.5000 37.0559
Subtotal (Total Children Is Unduplicated) 1065 4999.250000 185251.5000 37.0559
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 25 48.500000 3637.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 6 12.000000 900.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 4 8.000000 600.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 2.000000 150.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 25 50.000000 2775.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 411 816.250000 61218.7500 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 12 23.500000 1762.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 155 309.500000 23212.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 7 14.000000 1050.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 80 158.500000 11887.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 7 13.500000 1012.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 461 919.000000 51004.5000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 8 15.500000 860.2500 55.5000
OCTH-97165TL-OT EVAL LOW COMPLEXITY 1 1.000000 51.4100 51.4100
OCTH-97166-OT EVAL MODERATE COMPLEXITY 1 1.000000 51.4100 51.4100
OCTH-97166TL-OT EVAL MODERATE COMPLEXITY 4 4.000000 205.6400 51.4100
PSTH-97161TL-PT EVAL LOW COMPLEXITY 1 1.000000 51.4100 51.4100
PSTH-97162TL-PT EVAL MODERATE COMPLEXITY 1 1.000000 51.4100 51.4100
PSTH-97163TL-PT EVAL HIGH COMPLEXITY 5 5.000000 257.0500 51.4100
PSTH-97163TLGT-PT EVAL HIGH COMPLEXITY 1 1.000000 51.4100 51.4100
SCREEN-T1023-SCREENING 92 94.000000 4700.0000 50.0000
SPCH-92523TL-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 27 27.000000 1386.9900 51.3700
SPL-92526-TREATMENT OF SWALLOWING DYSFUNCTION 1 1.000000 52.5700 52.5700
SPL-92526TL-TREATMENT OF SWALLOWING DYSFUNCTION 13 78.000000 4121.5400 52.8403
Subtotal (Total Children Is Unduplicated) 636 2604.250000 171051.8400 65.6818
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 506 5297.250000 264812.5000 49.9906
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 13 13.750000 687.5000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 17 63.000000 4529.8400 71.9022
OCCT-97530GT-OT SESSION BY LICENSED OT 1 1.000000 71.4400 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 2 7.000000 403.2000 57.6000
OCCT-97530TL-OT SESSION BY LICENSED OT 48 497.000000 35698.0800 71.8271
OCCT-97530TLGT-OT SESSION BY LICENSED OT 3 5.500000 394.7400 71.7709
OCCT-97530TLGTHM-OT SESSION BY OT ASST 4 6.750000 388.3000 57.5259
OCCT-97530TLHM-OT SESSION BY OT ASST 22 175.000000 10070.0000 57.5429
PHY-97110-PT SESSION BY LICENSED PT 5 9.250000 662.7700 71.6508
PHY-97110HM-PT SESSION BY PT ASST 3 6.000000 345.3600 57.5600
PHY-97110HMGT-PT SESSION BY LICENSED PT ASST 1 1.000000 57.5600 57.5600
PHY-97110TL-PT SESSION BY LICENSED PT 43 410.250000 29479.2100 71.8567
PHY-97110TLGT-PT SESSION BY LICENSED PT 3 3.500000 250.5600 71.5886
PHY-97110TLGTHM-PT SESSION BY PT ASST 2 2.000000 115.1200 57.5600
PHY-97110TLHM-PT SESSION BY PT ASST 10 139.750000 8036.0100 57.5028
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 16 33.000000 2354.1000 71.3364
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 132 1310.500000 94038.6600 71.7578
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 1 1.000000 71.4400 71.4400
Subtotal (Total Children Is Unduplicated) 660 7982.500000 452466.3900 56.6823
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Total 15586.000000 808769.7300 51.8908
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Number of Children (Unduplicated) With at Least One Service 1112
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Center 52
Flag Claims Units Chgs Paid
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R 13 13.000000 685.6200 0.0000
U 0 0.000000 0.0000 0.0000
B 1969 2018.750000 108979.3200 130.2000
P 7117 7553.000000 354262.8600 474129.2400
D 42 62.250000 3851.5500 287.9000
S 575 506.250000 22078.2000 1963.3000
H 13 13.000000 847.6400 0.0000
T 2 3.000000 215.8800 0.0000
2867 5414.750000 317698.6600 0.0000
Other 1 2.000000 150.0000 150.0000
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Total 12599 15586.000000 808769.7300 476660.6400