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
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 741 1871.000000 69227.0000 37.0000
Subtotal (Total Children Is Unduplicated) 741 1871.000000 69227.0000 37.0000
-----------------------------------------------------------------------------------------------------------------------
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 65 118.500000 8887.5000 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 23 40.000000 3000.0000 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 80 142.500000 10687.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 7 11.500000 862.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 81 148.500000 8241.7500 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 65 118.000000 8850.0000 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) 183 646.000000 44783.4500 69.3242
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 42 100.500000 5025.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 86 87.000000 4350.0000 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 11 36.000000 2571.8400 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 22 49.750000 3554.1400 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 7 11.750000 839.4200 71.4400
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 4 7.000000 500.0800 71.4400
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 24 55.500000 3964.9200 71.4400
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 6 6.250000 388.9400 62.2304
Subtotal (Total Children Is Unduplicated) 195 367.250000 22158.7800 60.3370
-----------------------------------------------------------------------------------------------------------------------
Total 2884.250000 136169.2300 47.2113
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 779
-----------------------------------------------------------------------------------------------------------------------
Center 03
Flag Claims Units Chgs Paid
---------------------------------------------------------
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 2 2.000000 100.0000 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
24 27.000000 1907.9300 0.0000
Other 1480 1012.250000 41157.9000 0.0000
---------------------------------------------------------
Total 3438 2884.250000 136169.2300 0.0000