CMS/EIP Fiscal Report Center: 54
Services beginning 07/01/2022 ending 06/30/2023 Date of Report:07/25/2023 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 1835 14907.00000 553641.5500 37.1397
Subtotal (Total Children Is Unduplicated) 1835 14907.00000 553641.5500 37.1397
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 2 3.000000 225.0000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 18 32.500000 2400.0000 73.8462
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 1.000000 75.0000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 25 46.000000 3450.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 6 9.500000 712.5000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 16 31.000000 2325.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 12 24.000000 1800.0000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 7 14.000000 1050.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 2 4.000000 222.0000 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 23 45.500000 2525.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 26 42.500000 3187.5000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 101 183.000000 13462.5000 73.5656
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 48 81.000000 6037.5000 74.5370
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 271 506.500000 37987.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 53 89.500000 6675.0000 74.5810
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 134 240.000000 18000.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 11 20.500000 1137.7500 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 114 227.000000 12598.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 59 117.500000 8687.5000 73.9362
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 171 332.000000 24900.0000 75.0000
SCREEN-T1023-SCREENING 1 1.000000 50.0000 50.0000
Subtotal (Total Children Is Unduplicated) 814 2051.000000 147508.5000 71.9203
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 160 1060.750000 53012.5000 49.9764
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 158 821.250000 41031.0000 49.9616
OCCT-97530-OT SESSION BY LICENSED OT 22 47.180000 3387.2900 71.7950
OCCT-97530GT-OT SESSION BY LICENSED OT 6 15.500000 1114.8600 71.9265
OCCT-97530TL-OT SESSION BY LICENSED OT 104 888.750000 63729.7500 71.7072
OCCT-97530TLGT-OT SESSION BY LICENSED OT 69 248.250000 17834.0400 71.8390
PHY-97110-PT SESSION BY LICENSED PT 20 129.000000 9275.0400 71.8995
PHY-97110GT-PT SESSION BY LICENSED PT 1 1.000000 71.4400 71.4400
PHY-97110TL-PT SESSION BY LICENSED PT 98 845.750000 60747.3300 71.8266
PHY-97110TLGT-PT SESSION BY LICENSED PT 43 94.000000 6746.6900 71.7733
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 16 24.000000 1723.9200 71.8300
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 3 3.000000 215.8800 71.9600
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 69 496.250000 35653.9900 71.8468
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 39 148.750000 10686.8900 71.8446
Subtotal (Total Children Is Unduplicated) 509 4823.430000 305230.6200 63.2808
-----------------------------------------------------------------------------------------------------------------------
Total 21781.430000 1006380.6700 46.2036
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 1837
-----------------------------------------------------------------------------------------------------------------------
Center 54
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 12 14.000000 520.8000 0.0000
U 0 0.000000 0.0000 0.0000
B 2503 2401.250000 114818.0200 0.0000
P 20940 19366.180000 891041.8500 890153.5900
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 23455 21781.430000 1006380.6700 890153.5900