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
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 1088 3993.000000 147741.0000 37.0000
Subtotal (Total Children Is Unduplicated) 1088 3993.000000 147741.0000 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 9 17.500000 1312.5000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 4 7.500000 562.5000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 5 10.000000 750.0000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 2 4.000000 300.0000 75.0000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 15 29.000000 1609.5000 55.5000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 110 205.000000 15375.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 62 121.000000 9075.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 59 106.000000 7950.0000 75.0000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 163 305.000000 16927.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 4 7.500000 562.5000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 30 56.500000 4237.5000 75.0000
OCTH-97166TLGT-OT EVAL MODERATE COMPLEXITY 2 2.000000 102.1000 51.0500
PSTH-97162-PT EVAL MODERATE COMPLEXITY 4 4.000000 204.2000 51.0500
PSTH-97163-PT EVAL HIGH 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
SPCH-92524-BEHAV & QUAL ANALYSIS OF VOICE AND RES 2 2.000000 102.1000 51.0500
Subtotal (Total Children Is Unduplicated) 235 880.000000 59217.0500 67.2921
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 682 5284.000000 263801.0000 49.9245
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 62 280.000000 14000.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 47 318.000000 22717.9200 71.4400
OCCT-97530GT-OT SESSION BY LICENSED OT 3 10.000000 714.4000 71.4400
OCCT-97530TLGT-OT SESSION BY LICENSED OT 3 14.750000 1053.7400 71.4400
PHY-97110-PT SESSION BY LICENSED PT 50 421.250000 30094.1000 71.4400
PHY-97110GT-PT SESSION BY LICENSED PT 18 91.000000 6501.0400 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 111 855.000000 61081.2000 71.4400
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 8 45.000000 3214.8000 71.4400
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 2 9.000000 642.9600 71.4400
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 4 16.000000 1071.6400 66.9775
SPL-92508HA-GROUP SPL SESSION PER CHILD 1 8.000000 111.0400 13.8800
SPL-92508TLGT-SPL THERAPY SESSION BY LICENSED SLP 1 1.000000 13.8800 13.8800
Subtotal (Total Children Is Unduplicated) 844 7353.000000 405017.7200 55.0820
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Total 12226.000000 611975.7700 50.0553
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Number of Children (Unduplicated) With at Least One Service 1212
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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 5 6.000000 277.5000 527.2500
2263 7446.750000 415260.0800 0.0000
Other 132 241.250000 16021.5000 0.0000
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Total 6682 12226.000000 611975.7700 164349.1220