CMS/EIP Fiscal Report Center: 03
Services beginning 10/01/2021 ending 12/31/2021 Date of Report:02/04/2022 Page: 1
List order: No List
Payclass Filters:MED
Bill Flag Filter:RBPU
Eligibility Filter:All
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 356 970.750000 35917.7500 37.0000
Subtotal (Total Children Is Unduplicated) 356 970.750000 35917.7500 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 2.000000 150.0000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 1 1.500000 112.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 2 4.000000 300.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 2 3.500000 262.5000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 1 1.500000 112.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 3 6.000000 450.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 3 5.500000 305.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 55 101.500000 7612.5000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 1 2.000000 150.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 18 32.500000 2437.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 4 6.500000 487.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 62 110.000000 8250.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 6 9.500000 712.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 70 129.500000 7187.2500 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 9 16.500000 915.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 50 91.000000 6825.0000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 3 4.000000 300.0000 75.0000
OCTH-97165TL-OT EVAL LOW COMPLEXITY 2 2.000000 102.1000 51.0500
OCTH-97165TLGT-OT EVAL LOW COMPLEXITY 1 1.000000 51.0500 51.0500
PSTF-97164-PT RE-EVAL EST PLAN CARE 1 1.000000 51.0500 51.0500
PSTH-97161-PT EVAL LOW COMPLEXITY 1 1.000000 51.0500 51.0500
PSTH-97162TL-PT EVAL MODERATE COMPLEXITY 2 2.000000 102.1000 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 2 2.000000 102.1000 51.0500
SPCH-92523TL-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 4 4.000000 204.2000 51.0500
SPCH-92610-EVAL OF ORAL,PHARYNGEAL SWALLOWING FUNC 1 1.000000 44.5500 44.5500
Subtotal (Total Children Is Unduplicated) 154 541.000000 37278.9500 68.9075
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 40 97.500000 4875.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 77 79.750000 3987.5000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 1 4.000000 285.7600 71.4400
OCCT-97530GT-OT SESSION BY LICENSED OT 2 1.750000 125.0200 71.4400
OCCT-97530TL-OT SESSION BY LICENSED OT 10 35.000000 2500.4000 71.4400
OCCT-97530TLGT-OT SESSION BY LICENSED OT 3 2.500000 178.6000 71.4400
PHY-97110-PT SESSION BY LICENSED PT 4 5.250000 375.0600 71.4400
PHY-97110TL-PT SESSION BY LICENSED PT 21 44.750000 3196.9400 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 2 4.000000 285.7600 71.4400
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 4 4.000000 285.7600 71.4400
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 19 46.500000 3321.9600 71.4400
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 6 6.250000 388.9400 62.2304
Subtotal (Total Children Is Unduplicated) 174 331.250000 19806.7000 59.7938
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Total 1843.000000 93003.4000 50.4630
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Number of Children (Unduplicated) With at Least One Service 451
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Center 03
Flag Claims Units Chgs Paid
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R 68 37.000000 1369.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 1864 1806.000000 91634.4000 0.0000
P 0 0.000000 0.0000 0.0000
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
0 0.000000 0.0000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 1932 1843.000000 93003.4000 0.0000