CMS/EIP Fiscal Report Center: 55
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 1499 10840.75000 401236.2000 37.0118
Subtotal (Total Children Is Unduplicated) 1499 10840.75000 401236.2000 37.0118
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 51 109.166667 8187.5000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 5 10.000000 750.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 6 12.000000 900.0000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 18 36.000000 2700.0000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 3 6.000000 450.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 2 4.000000 300.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 21 42.000000 2331.0000 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 3 6.000000 333.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 716 1435.740534 107680.5400 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 108 213.666666 16025.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 90 179.000000 13425.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 18 36.000000 2700.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 169 337.000000 25275.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 37 73.000000 5475.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 459 928.000000 51504.0000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 82 164.000000 9102.0000 55.5000
OCTF-97168-OT RE-EVAL EST PLAN CARE 35 46.000000 2362.3400 51.3552
OCTH-97165-OT EVAL LOW COMPLEXITY 2 4.000000 205.6400 51.4100
OCTH-97166-OT EVAL MODERATE COMPLEXITY 11 11.000000 564.7900 51.3445
OCTH-97166TLGT-OT EVAL MODERATE COMPLEXITY 1 1.000000 51.4100 51.4100
OCTH-97167-OT EVAL HIGH COMPLEXITY 57 65.000000 3338.0500 51.3546
OCTH-97167GT-OT EVAL HIGH COMPLEXITY 3 3.000000 153.8700 51.2900
OCTH-97167TL-OT EVAL HIGH COMPLEXITY 1 1.000000 51.0500 51.0500
OCTH-97167TLGT-OT EVAL HIGH COMPLEXITY 1 2.000000 102.8200 51.4100
PSTF-97164-PT RE-EVAL EST PLAN CARE 10 14.000000 719.3800 51.3843
PSTH-97161-PT EVAL LOW COMPLEXITY 1 1.000000 51.4100 51.4100
PSTH-97163-PT EVAL HIGH COMPLEXITY 14 14.000000 718.6600 51.3329
PSTH-97163GT-PT EVAL HIGH COMPLEXITY 2 2.000000 102.4600 51.2300
SPCH-92521-EVAL OF SPEECH FLUENCY 2 2.000000 102.8200 51.4100
SPCH-92521TL-EVAL OF SPEECH FLUENCY 2 3.000000 154.2300 51.4100
SPCH-92521TLGT-EVAL OF SPEECH FLUENCY 1 1.000000 51.4100 51.4100
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 39 44.000000 2259.8800 51.3609
SPCH-92523GT-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 1 2.000000 102.8200 51.4100
SPCH-92523TL-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 4 5.000000 257.0500 51.4100
SPCH-92610-EVAL OF ORAL,PHARYNGEAL SWALLOWING FUNC 1 1.000000 44.8600 44.8600
Subtotal (Total Children Is Unduplicated) 1045 3815.573867 258682.9900 67.7966
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 360 5623.000000 281150.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 37 347.250000 17362.5000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 109 1579.250000 113522.4500 71.8838
OCCT-97530GT-OT SESSION BY LICENSED OT 2 25.000000 1792.7600 71.7104
OCCT-97530HM-OT SESSION BY OT ASST 159 2872.500000 165244.6000 57.5264
OCCT-97530HMGT-OT SESSION BY OT ASST 4 33.000000 1894.4000 57.4061
OCCT-97530TLHM-OT SESSION BY OT ASST 2 62.000000 3568.8000 57.5613
PHY-97110-PT SESSION BY LICENSED PT 50 933.250000 67076.5900 71.8742
PHY-97110GT-PT SESSION BY LICENSED PT 2 16.000000 1147.7200 71.7325
PHY-97110HM-PT SESSION BY PT ASST 63 1481.250000 85170.9500 57.4994
PHY-97110HMGT-PT SESSION BY LICENSED PT ASST 1 7.000000 402.9200 57.5600
PHY-97110TL-PT SESSION BY LICENSED PT 1 14.000000 1007.4400 71.9600
PHY-97110TLHM-PT SESSION BY PT ASST 1 7.000000 402.9200 57.5600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 220 2944.250000 211549.7300 71.8518
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 4 38.750000 2785.3300 71.8795
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 20 255.000000 18324.8400 71.8621
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 2 6.250000 449.3600 71.8976
Subtotal (Total Children Is Unduplicated) 769 16244.75000 972853.3100 59.8872
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Total 30901.073867 1632772.5000 52.8387
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Number of Children (Unduplicated) With at Least One Service 1555
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Center 55
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 3824 3868.703067 177195.0800 0.0000
P 10289 10237.706933 437675.1700 437140.5600
D 1 0.250000 9.3000 0.0000
S 10 13.413867 930.0400 37.5000
H 1 0.500000 18.6000 0.0000
T 0 0.000000 0.0000 0.0000
16176 16780.250000 1016935.0100 0.0000
Other 1 0.250000 9.3000 9.3000
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Total 30302 30901.073867 1632772.5000 437187.3600