CMS/EIP Fiscal Report Center: 06
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
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 1 0.750000 27.7500 37.0000
Subtotal (Total Children Is Unduplicated) 1 0.750000 27.7500 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 5 9.000000 606.7500 67.4167
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 1.500000 112.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 1.500000 112.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 2 3.500000 194.2500 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 5 8.500000 389.2500 45.7941
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 2 3.500000 262.5000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 129 213.500000 15831.3100 74.1513
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 2 4.000000 300.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 57 94.000000 7012.5000 74.6011
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 48 80.500000 6037.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 5 9.500000 527.2500 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 124 211.000000 11664.7500 55.2832
Subtotal (Total Children Is Unduplicated) 191 642.000000 43201.0600 67.2914
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EI Services,Class #03
AUD-92593TS-AUDIOLOGY SERVICES (Biaural) 1 1.000000 50.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 7 27.000000 1350.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 19 86.750000 6029.8600 69.5085
OCCT-97530GT-OT SESSION BY LICENSED OT 8 13.000000 828.0500 63.6962
OCCT-97530HM-OT SESSION BY OT ASST 10 45.000000 1481.4000 32.9200
OCCT-97530HMGT-OT SESSION BY OT ASST 1 2.500000 143.0000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 25 93.750000 6532.5700 69.6807
PHY-97110GT-PT SESSION BY LICENSED PT 5 12.500000 893.0000 71.4400
PHY-97110HM-PT SESSION BY PT ASST 9 32.500000 1857.7000 57.1600
PHY-97110HMGT-PT SESSION BY LICENSED PT ASST 2 3.500000 200.0600 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 87 350.500000 23819.8700 67.9597
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 33 99.250000 7030.4200 70.8355
Subtotal (Total Children Is Unduplicated) 164 767.250000 50215.9300 65.4492
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Total 1410.000000 93444.7400 66.2729
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Number of Children (Unduplicated) With at Least One Service 348
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Center 06
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 514 322.250000 20723.4000 20723.4000
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
1163 1087.000000 72693.5900 0.0000
Other 1 0.750000 27.7500 0.0000
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Total 1678 1410.000000 93444.7400 20723.4000