CMS/EIP Fiscal Report Center: 53
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 827 2041.250000 75480.0000 36.9773
Subtotal (Total Children Is Unduplicated) 827 2041.250000 75480.0000 36.9773
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 2 4.000000 300.0000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 8 14.500000 1087.5000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 8 13.500000 1012.5000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 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 17 35.000000 1942.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 2 3.500000 262.5000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 64 110.000000 8250.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 4 6.500000 487.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 55 94.500000 7087.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 1 1.500000 112.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 28 42.000000 3150.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 2 4.000000 222.0000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 118 209.500000 11627.2500 55.5000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 32 57.000000 4275.0000 75.0000
Subtotal (Total Children Is Unduplicated) 199 599.500000 40116.7500 66.9170
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 88 258.750000 12937.5000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 337 1476.750000 73837.5000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 15 23.000000 1643.1200 71.4400
OCCT-97530GT-OT SESSION BY LICENSED OT 4 5.500000 392.9200 71.4400
OCCT-97530TL-OT SESSION BY LICENSED OT 12 16.000000 1143.0400 71.4400
OCCT-97530TLGT-OT SESSION BY LICENSED OT 44 147.250000 10519.5400 71.4400
PHY-97110-PT SESSION BY LICENSED PT 1 5.750000 410.7800 71.4400
PHY-97110GT-PT SESSION BY LICENSED PT 2 5.500000 392.9200 71.4400
PHY-97110TL-PT SESSION BY LICENSED PT 25 81.500000 5822.3600 71.4400
PHY-97110TLGT-PT SESSION BY LICENSED PT 19 47.000000 3357.6800 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 9 15.000000 1071.6000 71.4400
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 21 78.000000 5572.3200 71.4400
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 60 256.750000 18284.6600 71.2158
SPL-92508TLGT-SPL THERAPY SESSION BY LICENSED SLP 1 1.000000 13.8800 13.8800
Subtotal (Total Children Is Unduplicated) 510 2417.750000 135399.8200 56.0024
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Total 5058.500000 250996.5700 49.6188
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Number of Children (Unduplicated) With at Least One Service 955
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Center 53
Flag Claims Units Chgs Paid
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R 34 31.750000 1588.0300 0.0000
U 0 0.000000 0.0000 0.0000
B 2051 1892.500000 93358.4400 1055.0000
P 1440 1401.500000 66480.6400 66462.1400
D 46 46.250000 3311.2200 0.0000
S 148 119.000000 6932.4800 1572.5000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
1415 1446.000000 73135.4300 0.0000
Other 154 121.500000 6190.3300 0.0000
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Total 5288 5058.500000 250996.5700 69089.6400