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:TPIN
Eligibility Filter:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 2 3.500000 262.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 1.500000 112.5000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 1 1.500000 112.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 2 3.500000 262.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 2 3.500000 262.5000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 1 1.500000 112.5000 75.0000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 60 106.000000 7950.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 4 7.000000 525.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 23 43.000000 3225.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 1 1.500000 112.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 58 101.500000 7612.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 2 3.500000 262.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 4 7.500000 416.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 43 75.000000 5625.0000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 2 3.000000 225.0000 75.0000
OCTH-97165-OT EVAL LOW COMPLEXITY 4 4.000000 204.2000 51.0500
OCTH-97165GT-OT EVAL LOW COMPLEXITY 1 1.000000 51.0500 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 2 2.000000 102.1000 51.0500
PSTF-97164-PT RE-EVAL EST PLAN CARE 1 1.000000 51.0500 51.0500
PSTH-97161-PT EVAL LOW COMPLEXITY 3 3.000000 173.5400 57.8467
PSTH-97162-PT EVAL MODERATE COMPLEXITY 1 1.000000 51.0500 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 10 10.000000 530.8900 53.0890
Subtotal (Total Children Is Unduplicated) 161 385.000000 28242.6300 73.3575
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EI Services,Class #03
OCCT-97530-OT SESSION BY LICENSED OT 21 64.000000 4283.8400 66.9350
OCCT-97530GT-OT SESSION BY LICENSED OT 6 10.750000 722.9800 67.2540
PHY-97110-PT SESSION BY LICENSED PT 23 68.250000 4875.7800 71.4400
PHY-97110GT-PT SESSION BY LICENSED PT 2 2.000000 142.8800 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 69 200.500000 14221.9900 70.9326
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 14 13.750000 982.3000 71.4400
Subtotal (Total Children Is Unduplicated) 120 359.250000 25229.7700 70.2290
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Total 744.250000 53472.4000 71.8474
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Number of Children (Unduplicated) With at Least One Service 238
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Center 03
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 0 0.000000 0.0000 0.0000
P 36 35.750000 2177.6300 2177.6300
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
550 687.000000 49682.2700 0.0000
Other 13 21.500000 1612.5000 0.0000
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Total 599 744.250000 53472.4000 2177.6300