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
Agency Filter:EIP DEI DEIP
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
-----------------------------------------------------------------------------------------------------------------------
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 17 31.000000 2287.5000 73.7903
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 4 7.000000 525.0000 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 2 4.000000 300.0000 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 15 30.000000 1665.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 16 26.000000 1950.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 74 140.500000 10275.0000 73.1317
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 182 344.500000 25837.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 38 67.500000 5062.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 89 169.500000 12712.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 8 15.500000 860.2500 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 74 147.500000 8186.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 40 79.500000 5962.5000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 145 284.500000 21337.5000 75.0000
SCREEN-T1023-SCREENING 1 1.000000 50.0000 50.0000
Subtotal (Total Children Is Unduplicated) 566 1497.500000 108108.5000 72.1927
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 163 1103.750000 55162.5000 49.9773
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 157 826.750000 41306.0000 49.9619
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 106 896.500000 64285.8800 71.7076
OCCT-97530TLGT-OT SESSION BY LICENSED OT 70 257.250000 18480.6400 71.8392
PHY-97110-PT SESSION BY LICENSED PT 20 138.000000 9917.2400 71.8641
PHY-97110GT-PT SESSION BY LICENSED PT 2 2.000000 143.4000 71.7000
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 19 40.000000 2874.7600 71.8690
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 4 4.000000 287.3200 71.8300
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 70 503.250000 36155.6300 71.8443
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) 517 4996.540000 316542.2000 63.3523
-----------------------------------------------------------------------------------------------------------------------
Total 19369.790000 902860.3500 46.6118
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 1553
-----------------------------------------------------------------------------------------------------------------------
Center 54
Flag Claims Units Chgs Paid
---------------------------------------------------------
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 18771 16798.930000 776716.0300 776235.4500
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
2 2.250000 83.7000 0.0000
Other 361 320.190000 17058.7800 1550.8300
---------------------------------------------------------
Total 21552 19369.790000 902860.3500 777823.4800