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
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 1232 5394.750000 199487.5000 36.9781
Subtotal (Total Children Is Unduplicated) 1232 5394.750000 199487.5000 36.9781
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
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 9 10.000000 750.0000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 4 9.000000 675.0000 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 14 18.500000 1026.7500 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 66 72.500000 5437.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 177 212.000000 15900.0000 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 259 365.000000 20257.5000 55.5000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 91 113.000000 8455.5000 74.8274
MED-99201-OUTPATIENT VISIT, NEW, 10 MINS 4 4.000000 121.4000 30.3500
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 30 30.000000 1935.9100 64.5303
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 3 3.000000 78.0100 26.0033
OCTH-97166-OT EVAL MODERATE COMPLEXITY 1 1.000000 51.0500 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 10 10.000000 510.5000 51.0500
PSTH-97162-PT EVAL MODERATE COMPLEXITY 3 3.000000 153.1500 51.0500
PSTH-97162GT-PT EVAL MODERATE COMPLEXITY 2 2.000000 102.1000 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 4 4.000000 204.2000 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 1 1.000000 51.0500 51.0500
Subtotal (Total Children Is Unduplicated) 302 864.000000 56116.1700 64.9493
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 868 7839.500000 391975.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 52 222.000000 11100.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 12 51.000000 3643.4400 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 22 174.500000 9981.4000 57.2000
OCCT-97530HMGT-OT SESSION BY OT ASST 1 2.000000 114.4000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 4 25.500000 1821.7200 71.4400
PHY-97110HM-PT SESSION BY PT ASST 22 188.000000 10746.0800 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 4 14.500000 1035.8800 71.4400
Subtotal (Total Children Is Unduplicated) 925 8517.000000 430417.9200 50.5363
-----------------------------------------------------------------------------------------------------------------------
Total 14775.750000 686021.5900 46.4289
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 1485
-----------------------------------------------------------------------------------------------------------------------
Center 04
Flag Claims Units Chgs Paid
---------------------------------------------------------
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 828 1362.000000 54568.8400 53062.4600
D 9 9.000000 333.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 2371 8522.000000 430346.9300 0.0000
T 0 0.000000 0.0000 0.0000
225 273.250000 16752.0700 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 6238 14775.750000 686021.5900 53062.4600