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:TPIN
Eligibility Filter:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 1 2.000000 150.0000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 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-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 3 5.500000 255.2500 46.4091
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 44 82.000000 5865.0000 71.5244
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 27 49.000000 3470.6900 70.8304
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 4 7.500000 562.5000 75.0000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 89 169.500000 8942.2500 52.7566
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 4 8.000000 600.0000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 14 27.500000 2062.5000 75.0000
PSTF-97164GT-PT RE-EVAL EST PLAN CARE 1 1.000000 51.0500 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 2 2.000000 102.1000 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 1 1.000000 51.0500 51.0500
SPCH-92523GT-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 1 1.000000 51.0500 51.0500
SPCH-92524-BEHAV & QUAL ANALYSIS OF VOICE AND RES 2 2.000000 102.1000 51.0500
Subtotal (Total Children Is Unduplicated) 137 362.000000 22565.5400 62.3357
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 2 7.000000 350.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 29 180.000000 12172.9500 67.6275
OCCT-97530GT-OT SESSION BY LICENSED OT 1 1.000000 71.4400 71.4400
OCCT-97530TLGT-OT SESSION BY LICENSED OT 1 2.000000 142.8800 71.4400
PHY-97110-PT SESSION BY LICENSED PT 36 252.000000 17362.1600 68.8975
PHY-97110GT-PT SESSION BY LICENSED PT 6 15.000000 1071.6000 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 86 547.250000 37567.6400 68.6480
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 7 38.000000 2514.7200 66.1768
Subtotal (Total Children Is Unduplicated) 137 1042.250000 71253.3900 68.3650
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Total 1404.250000 93818.9300 66.8107
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Number of Children (Unduplicated) With at Least One Service 252
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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 0 0.000000 0.0000 0.0000
P 349 883.000000 58516.5400 58947.8900
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 32 70.500000 4295.8000 4262.5500
198 438.750000 30145.5900 0.0000
Other 6 12.000000 861.0000 0.0000
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Total 585 1404.250000 93818.9300 63210.4400