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: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 9 20.500000 758.5000 37.0000
Subtotal (Total Children Is Unduplicated) 9 20.500000 758.5000 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 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 80 180.000000 11707.5000 65.0417
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 7 14.000000 1050.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 31 68.000000 4635.0000 68.1618
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 15 32.000000 2250.0000 70.3125
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 9 22.000000 1480.0000 67.2727
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 87 178.000000 9636.0000 54.1348
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 5 10.000000 555.0000 55.5000
OCTH-97165-OT EVAL LOW COMPLEXITY 1 1.000000 51.0500 51.0500
OCTH-97165GT-OT EVAL LOW COMPLEXITY 1 1.000000 51.0500 51.0500
OCTH-97166-OT EVAL MODERATE COMPLEXITY 1 1.000000 51.0500 51.0500
OCTH-97166GT-OT EVAL MODERATE COMPLEXITY 1 1.000000 51.0500 51.0500
PSTH-97161-PT EVAL LOW COMPLEXITY 1 1.000000 51.0500 51.0500
SCREEN-T1023-SCREENING 13 14.000000 650.0000 46.4286
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 5 5.000000 255.2500 51.0500
SPCH-92524-BEHAV & QUAL ANALYSIS OF VOICE AND RES 1 1.000000 51.0500 51.0500
Subtotal (Total Children Is Unduplicated) 118 535.000000 32936.0500 61.5627
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 148 792.250000 39387.5000 49.7160
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 9 24.750000 1237.5000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 22 84.000000 5509.4400 65.5886
OCCT-97530GT-OT SESSION BY LICENSED OT 5 13.000000 857.2800 65.9446
OCCT-97530HM-OT SESSION BY OT ASST 11 43.000000 2288.0000 53.2093
PHY-97110-PT SESSION BY LICENSED PT 22 146.250000 9608.6800 65.7004
PHY-97110GT-PT SESSION BY LICENSED PT 2 2.500000 178.6000 71.4400
PHY-97110HM-PT SESSION BY PT ASST 3 5.000000 285.8000 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 146 912.500000 59294.4700 64.9802
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 11 35.250000 2518.2600 71.4400
Subtotal (Total Children Is Unduplicated) 300 2058.500000 121165.5300 58.8611
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Total 2614.000000 154860.0800 59.2426
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Number of Children (Unduplicated) With at Least One Service 352
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Center 52
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 133 170.500000 9217.6000 6760.5400
D 211 237.500000 12225.0000 130.0000
S 1 2.000000 150.0000 130.0000
H 179 241.000000 15506.3200 35.0000
T 745 1238.000000 75032.0900 70054.4000
393 724.500000 42710.5700 53.6100
Other 1 0.500000 18.5000 0.0000
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Total 1663 2614.000000 154860.0800 77163.5500