CMS/EIP Fiscal Report Center: 52
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 510 1609.500000 59449.7500 36.9368
Subtotal (Total Children Is Unduplicated) 510 1609.500000 59449.7500 36.9368
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 3 6.000000 450.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 3 6.000000 450.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 5 10.000000 555.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 102 201.500000 15112.5000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 17 33.500000 2512.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 29 58.000000 4350.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 20 40.000000 3000.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 20 40.000000 3000.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 123 245.500000 13625.2500 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 15 29.500000 1637.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 2.000000 150.0000 75.0000
OCTH-97165TLGT-OT EVAL LOW COMPLEXITY 1 1.000000 51.0500 51.0500
OCTH-97166TL-OT EVAL MODERATE COMPLEXITY 3 3.000000 153.1500 51.0500
OCTH-97167TL-OT EVAL HIGH COMPLEXITY 2 2.000000 102.1000 51.0500
PSTH-97161TL-PT EVAL LOW COMPLEXITY 1 1.000000 51.0500 51.0500
PSTH-97162GT-PT EVAL MODERATE COMPLEXITY 1 1.000000 51.0500 51.0500
PSTH-97163TL-PT EVAL HIGH COMPLEXITY 1 1.000000 51.0500 51.0500
SCREEN-T1023-SCREENING 29 29.000000 1450.0000 50.0000
SPCH-92523TL-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 7 7.000000 357.3500 51.0500
Subtotal (Total Children Is Unduplicated) 185 721.000000 47409.3000 65.7549
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 280 1381.500000 69075.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 12 12.750000 637.5000 50.0000
OCCT-97530TL-OT SESSION BY LICENSED OT 27 145.000000 10358.8000 71.4400
OCCT-97530TLGT-OT SESSION BY LICENSED OT 1 1.000000 71.4400 71.4400
OCCT-97530TLHM-OT SESSION BY OT ASST 12 51.750000 2960.1000 57.2000
PHY-97110TL-PT SESSION BY LICENSED PT 28 145.750000 10412.3800 71.4400
PHY-97110TLGT-PT SESSION BY LICENSED PT 2 9.250000 660.8200 71.4400
PHY-97110TLHM-PT SESSION BY PT ASST 1 0.750000 42.8700 57.1600
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 1 0.750000 53.5800 71.4400
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 116 634.000000 45292.9600 71.4400
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 10 21.000000 1500.2400 71.4400
Subtotal (Total Children Is Unduplicated) 407 2403.500000 141065.6900 58.6918
-----------------------------------------------------------------------------------------------------------------------
Total 4734.000000 247924.7400 52.3711
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 591
-----------------------------------------------------------------------------------------------------------------------
Center 52
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 628 657.500000 29680.9700 252.1000
P 1866 2077.000000 97886.1500 102757.2300
D 2 3.250000 120.2500 0.0000
S 20 25.250000 1236.3200 101.7500
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
1012 1960.750000 118621.8000 0.0000
Other 15 10.250000 379.2500 0.0000
---------------------------------------------------------
Total 3543 4734.000000 247924.7400 103111.0800