CMS/EIP Fiscal Report Center: 07
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 2 1.250000 46.2500 37.0000
Subtotal (Total Children Is Unduplicated) 2 1.250000 46.2500 37.0000
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Screening, Eval, and Assessment,Class #02
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 2 2.000000 29.1600 14.5800
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 2.000000 150.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 1 2.000000 150.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 2.000000 111.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 28 54.701400 4102.6050 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 18 35.003500 2625.2625 75.0000
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 1 2.000000 150.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 4 8.000000 600.0000 75.0000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 21 41.169100 3087.6825 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 12 24.000000 1800.0000 75.0000
OCTH-97165-OT EVAL LOW COMPLEXITY 1 1.000000 51.0500 51.0500
OCTH-97166-OT EVAL MODERATE COMPLEXITY 3 3.000000 153.1500 51.0500
OCTH-97166GT-OT EVAL MODERATE COMPLEXITY 1 1.000000 51.0500 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 1 1.000000 51.0500 51.0500
PSTF-97164-PT RE-EVAL EST PLAN CARE 2 3.000000 153.1500 51.0500
PSTH-97162-PT EVAL MODERATE COMPLEXITY 2 2.000000 102.1000 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 13 13.000000 663.6500 51.0500
SPCH-92523GT-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 1 1.000000 51.0500 51.0500
Subtotal (Total Children Is Unduplicated) 108 203.874000 14531.9600 71.2791
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 40 202.500000 10125.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 9 28.500000 1425.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 21 108.750000 7739.1000 71.1641
OCCT-97530GT-OT SESSION BY LICENSED OT 3 3.000000 214.3200 71.4400
PHY-97110-PT SESSION BY LICENSED PT 18 84.500000 6027.5700 71.3322
PHY-97110GT-PT SESSION BY LICENSED PT 3 2.750000 196.4600 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 73 382.250000 27010.3900 70.6616
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 5 6.000000 428.6400 71.4400
Subtotal (Total Children Is Unduplicated) 145 818.250000 53166.4800 64.9758
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Total 1023.374000 67744.6900 66.1974
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Number of Children (Unduplicated) With at Least One Service 234
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Center 07
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 416 900.124000 58548.4400 58405.5500
D 4 8.000000 600.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 6 12.000000 900.0000 0.0000
T 0 0.000000 0.0000 0.0000
52 102.750000 7677.7500 0.0000
Other 1 0.500000 18.5000 0.0000
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Total 479 1023.374000 67744.6900 58405.5500