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:OTHER
Eligibility Filter:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
CASE-CASE-NON-TCM CASE MANAGEMENT 1 0.250000 9.3000 37.2000
TCM-T1017TL-TARGETED CASE MANAGEMENT 59 193.250000 7233.5500 37.4310
Subtotal (Total Children Is Unduplicated) 59 193.500000 7242.8500 37.4307
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
EVAL-96111-DEVELOPMENTAL EVALUATION 1 2.000000 100.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 2.000000 150.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 21 42.000000 3150.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 8 16.000000 1200.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 4 8.000000 600.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 3 6.000000 450.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 10 20.000000 1500.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 1 2.000000 111.0000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 2 4.000000 222.0000 55.5000
OCTF-97168-OT RE-EVAL EST PLAN CARE 1 1.000000 51.4100 51.4100
OCTH-97167-OT EVAL HIGH COMPLEXITY 1 1.000000 51.0500 51.0500
PSTF-97164-PT RE-EVAL EST PLAN CARE 2 2.000000 102.4600 51.2300
PSTH-97163-PT EVAL HIGH COMPLEXITY 2 2.000000 102.1000 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 3 3.000000 153.5100 51.1700
Subtotal (Total Children Is Unduplicated) 40 113.000000 8093.5300 71.6242
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 15 104.750000 5237.5000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 17 107.750000 7720.4100 71.6511
OCCT-97530HM-OT SESSION BY OT ASST 13 118.250000 6785.1000 57.3793
PHY-97110-PT SESSION BY LICENSED PT 13 104.500000 7488.3600 71.6589
PHY-97110HM-PT SESSION BY PT ASST 6 51.000000 2920.1600 57.2580
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 31 244.750000 17536.9400 71.6525
Subtotal (Total Children Is Unduplicated) 72 731.000000 47688.4700 65.2373
-----------------------------------------------------------------------------------------------------------------------
Total 1037.500000 63024.8500 60.7468
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 112
-----------------------------------------------------------------------------------------------------------------------
Center 55
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 0 0.000000 0.0000 0.0000
P 682 703.500000 46311.2400 46311.2400
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
375 334.000000 16713.6100 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1057 1037.500000 63024.8500 46311.2400