CMS/EIP Fiscal Report Center: 09
Services beginning 10/01/2021 ending 12/31/2021 Date of Report:02/04/2022 Page: 1
List order: No List
Payclass Filters:MED
Bill Flag Filter:RBPU
Eligibility Filter:All
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 1084 3975.750000 147102.7500 37.0000
Subtotal (Total Children Is Unduplicated) 1084 3975.750000 147102.7500 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 2 3.500000 262.5000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 2 3.500000 262.5000 75.0000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 11 21.000000 1165.5000 55.5000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 46 81.000000 6075.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 25 47.000000 3525.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 2 3.000000 225.0000 75.0000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 123 231.500000 12848.2500 55.5000
OCTH-97166TLGT-OT EVAL MODERATE COMPLEXITY 2 2.000000 102.1000 51.0500
SPCH-92523TLGT-EVAL OF SPCH SOUND PROD; EVAL LANG COM 1 1.000000 44.5500 44.5500
Subtotal (Total Children Is Unduplicated) 171 393.500000 24510.4000 62.2882
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 4 4.000000 200.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 28 125.000000 6250.0000 50.0000
OCCT-97530GT-OT SESSION BY LICENSED OT 1 2.000000 142.8800 71.4400
OCCT-97530TLGT-OT SESSION BY LICENSED OT 3 14.750000 1053.7400 71.4400
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 2 3.000000 214.3200 71.4400
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 3 13.000000 928.7200 71.4400
SPL-92508TLGT-SPL THERAPY SESSION BY LICENSED SLP 1 1.000000 13.8800 13.8800
Subtotal (Total Children Is Unduplicated) 34 162.750000 8803.5400 54.0924
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Total 4532.000000 180416.6900 39.8095
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Number of Children (Unduplicated) With at Least One Service 1110
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Center 09
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 377 415.250000 16967.8200 166.5000
P 3905 4116.750000 163448.8700 163655.3720
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
0 0.000000 0.0000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 4282 4532.000000 180416.6900 163821.8720