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:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 1866 15094.00000 560579.3500 37.1392
Subtotal (Total Children Is Unduplicated) 1866 15094.00000 560579.3500 37.1392
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 4 6.500000 487.5000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 28 52.500000 3900.0000 74.2857
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 28 51.500000 3862.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 8 13.500000 1012.5000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 17 33.000000 2475.0000 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 11 21.000000 1575.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 16 31.000000 1720.5000 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 57 116.000000 6438.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 42 70.000000 5250.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 197 386.000000 28687.5000 74.3199
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 49 83.000000 6187.5000 74.5482
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 282 528.000000 39600.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 54 91.500000 6825.0000 74.5902
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 175 321.500000 24112.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 93 169.500000 9407.2500 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 495 941.000000 52225.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 66 129.000000 9550.0000 74.0310
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 238 472.500000 35437.5000 75.0000
SCREEN-T1023-SCREENING 1 1.000000 50.0000 50.0000
Subtotal (Total Children Is Unduplicated) 968 3543.000000 240678.7500 67.9308
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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 517 2774.500000 138653.5000 49.9742
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 108 919.500000 65940.4400 71.7134
OCCT-97530TLGT-OT SESSION BY LICENSED OT 72 259.250000 18624.0400 71.8381
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 99 889.750000 63905.7700 71.8244
PHY-97110TLGT-PT SESSION BY LICENSED PT 44 96.000000 6890.0900 71.7718
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) 1095 12452.54000 700762.3000 56.2746
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Total 31089.540000 1502020.4000 48.3127
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Number of Children (Unduplicated) With at Least One Service 1871
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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 2503 2401.250000 114818.0200 0.0000
P 20940 19366.180000 891041.8500 890153.5900
D 91 97.000000 5971.6900 0.0000
S 33 31.860000 1884.2700 37.2000
H 18 18.560000 1265.7200 0.0000
T 0 0.000000 0.0000 0.0000
8202 8822.500000 468449.4700 0.0000
Other 377 338.190000 18068.5800 1633.3300
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Total 32176 31089.540000 1502020.4000 891824.1200