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:Part C (excluding not eligible)
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 1552 12875.75000 478209.6500 37.1403
Subtotal (Total Children Is Unduplicated) 1552 12875.75000 478209.6500 37.1403
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 3 5.000000 375.0000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 25 47.000000 3487.5000 74.2021
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 18 33.500000 2512.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 6 11.000000 825.0000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 14 27.500000 2062.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 7 14.000000 1050.0000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 4 7.000000 525.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 12 23.500000 1304.2500 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 42 89.000000 4939.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 31 52.500000 3937.5000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 144 293.500000 21750.0000 74.1056
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 37 67.500000 5025.0000 74.4444
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 183 346.500000 25987.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 39 69.500000 5212.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 106 203.000000 15225.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 65 119.000000 6604.5000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 334 650.000000 36075.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 45 87.500000 6562.5000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 175 347.500000 26062.5000 75.0000
SCREEN-T1023-SCREENING 1 1.000000 50.0000 50.0000
Subtotal (Total Children Is Unduplicated) 669 2495.000000 169573.2500 67.9652
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 624 6085.250000 304148.5000 49.9813
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 516 2760.000000 137928.5000 49.9741
OCCT-97530-OT SESSION BY LICENSED OT 30 78.160000 5611.5000 71.7950
OCCT-97530GT-OT SESSION BY LICENSED OT 8 17.130000 1231.6600 71.9008
OCCT-97530TL-OT SESSION BY LICENSED OT 107 898.500000 64429.8000 71.7082
OCCT-97530TLGT-OT SESSION BY LICENSED OT 70 257.250000 18480.6400 71.8392
PHY-97110-PT SESSION BY LICENSED PT 36 222.000000 15957.7200 71.8816
PHY-97110GT-PT SESSION BY LICENSED PT 6 13.000000 932.8800 71.7600
PHY-97110TL-PT SESSION BY LICENSED PT 98 884.750000 63548.5700 71.8266
PHY-97110TLGT-PT SESSION BY LICENSED PT 43 95.250000 6836.2500 71.7717
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 53 421.000000 30284.2400 71.9341
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 17 21.000000 1509.6000 71.8857
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 71 506.250000 36371.5100 71.8450
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 39 148.750000 10686.8900 71.8446
SPL-92508TLGT-SPL THERAPY SESSION BY LICENSED SLP 1 1.000000 13.9600 13.9600
Subtotal (Total Children Is Unduplicated) 1091 12409.29000 697972.2200 56.2459
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Total 27780.040000 1345755.1200 48.4432
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Number of Children (Unduplicated) With at Least One Service 1557
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Center 54
Flag Claims Units Chgs Paid
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R 12 14.000000 520.8000 0.0000
U 0 0.000000 0.0000 0.0000
B 2268 2096.000000 99920.9600 0.0000
P 18772 16799.930000 776766.0300 776285.4500
D 88 91.000000 5521.6900 0.0000
S 32 28.860000 1772.6700 37.2000
H 18 18.560000 1265.7200 0.0000
T 0 0.000000 0.0000 0.0000
7973 8411.500000 442928.4700 0.0000
Other 361 320.190000 17058.7800 1550.8300
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Total 29524 27780.040000 1345755.1200 777873.4800