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
Eligibility Filter:Not Part C
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 314 2218.250000 82369.7000 37.1327
Subtotal (Total Children Is Unduplicated) 314 2218.250000 82369.7000 37.1327
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 1.500000 112.5000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 3 5.500000 412.5000 75.0000
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 10 18.000000 1350.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 2 2.500000 187.5000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 3 5.500000 412.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 5 10.000000 750.0000 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 4 7.500000 416.2500 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 15 27.000000 1498.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 11 17.500000 1312.5000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 53 92.500000 6937.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 12 15.500000 1162.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 99 181.500000 13612.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 15 22.000000 1612.5000 73.2955
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 69 118.500000 8887.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 28 50.500000 2802.7500 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 161 291.000000 16150.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 21 41.500000 2987.5000 71.9880
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 63 125.000000 9375.0000 75.0000
Subtotal (Total Children Is Unduplicated) 299 1048.000000 71105.5000 67.8488
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EI Services,Class #03
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 1 14.500000 725.0000 50.0000
OCCT-97530TL-OT SESSION BY LICENSED OT 1 21.000000 1510.6400 71.9352
OCCT-97530TLGT-OT SESSION BY LICENSED OT 2 2.000000 143.4000 71.7000
PHY-97110TL-PT SESSION BY LICENSED PT 1 5.000000 357.2000 71.4400
PHY-97110TLGT-PT SESSION BY LICENSED PT 1 0.750000 53.8400 71.7867
Subtotal (Total Children Is Unduplicated) 4 43.250000 2790.0800 64.5105
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Total 3309.500000 156265.2800 47.2172
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Number of Children (Unduplicated) With at Least One Service 314
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Center 54
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 235 305.250000 14897.0600 0.0000
P 2168 2566.250000 114275.8200 113868.1400
D 3 6.000000 450.0000 0.0000
S 1 3.000000 111.6000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
229 411.000000 25521.0000 0.0000
Other 16 18.000000 1009.8000 82.5000
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Total 2652 3309.500000 156265.2800 113950.6400