CMS/EIP Fiscal Report Center: 04
Services beginning 10/01/2021 ending 12/31/2021 Date of Report:02/04/2022 Page: 1
List order: No List
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 829 723.500000 26769.5000 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 1609 7209.750000 266531.5000 36.9682
Subtotal (Total Children Is Unduplicated) 1653 7933.250000 293301.0000 36.9711
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Screening, Eval, and Assessment,Class #02
EVAL-96111-DEVELOPMENTAL EVALUATION 14 12.250000 612.5000 50.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 2 2.000000 150.0000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 15 16.500000 1237.5000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 8 17.000000 1275.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 1.000000 55.5000 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 21 35.500000 1970.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 1 1.000000 75.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 91 101.000000 7545.7500 74.7104
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 1 1.000000 75.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 243 295.500000 22162.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 1 1.000000 75.0000 75.0000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 359 650.000000 36075.0000 55.5000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 203 348.000000 26061.0000 74.8879
MED-99201-OUTPATIENT VISIT, NEW, 10 MINS 5 5.000000 151.7500 30.3500
MED-99202-OUTPATIENT VISIT, NEW, 20 MINS 1 1.000000 304.0000 304.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 84 84.000000 8585.9400 102.2136
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 5 5.000000 124.8500 24.9700
OCTH-97165-OT EVAL LOW COMPLEXITY 1 1.000000 51.0500 51.0500
OCTH-97166-OT EVAL MODERATE COMPLEXITY 4 4.000000 204.2000 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 14 14.000000 714.7000 51.0500
OCTH-97167GT-OT EVAL HIGH COMPLEXITY 1 1.000000 51.0500 51.0500
PSTH-97162-PT EVAL MODERATE COMPLEXITY 8 8.000000 381.0800 47.6350
PSTH-97162GT-PT EVAL MODERATE COMPLEXITY 3 3.000000 153.1500 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 5 5.000000 255.2500 51.0500
PSTH-97163GT-PT EVAL HIGH COMPLEXITY 1 1.000000 51.0500 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 5 6.000000 306.3000 51.0500
SPCH-92524-BEHAV & QUAL ANALYSIS OF VOICE AND RES 4 4.000000 204.2000 51.0500
SPCH-92610-EVAL OF ORAL,PHARYNGEAL SWALLOWING FUNC 3 3.000000 133.6500 44.5500
Subtotal (Total Children Is Unduplicated) 446 1626.750000 109042.2200 67.0307
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 31 49.750000 2487.5000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1045 9421.250000 471062.5000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 66 299.750000 14987.5000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 1016 9475.000000 94750.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 40 183.000000 12832.4800 70.1228
OCCT-97530HM-OT SESSION BY OT ASST 34 234.250000 13399.1000 57.2000
OCCT-97530HMGT-OT SESSION BY OT ASST 1 2.000000 114.4000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 25 134.000000 9332.0800 69.6424
PHY-97110HM-PT SESSION BY PT ASST 26 228.000000 13032.4800 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 36 180.000000 12859.2000 71.4400
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 1 1.000000 57.2000 57.2000
Subtotal (Total Children Is Unduplicated) 1190 20208.00000 644914.4400 31.9138
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Total 29768.000000 1047257.6600 35.1807
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Number of Children (Unduplicated) With at Least One Service 1936
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Center 04
Flag Claims Units Chgs Paid
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R 13 24.500000 906.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 2792 4585.000000 183114.2500 0.0000
P 4038 12750.500000 251815.4000 243683.4300
D 9 9.000000 333.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 2391 8594.000000 432448.6900 430.0000
T 0 0.000000 0.0000 0.0000
3145 3546.500000 162109.0400 0.0000
Other 103 258.500000 16530.7800 2020.4800
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Total 12491 29768.000000 1047257.6600 246133.9100