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: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 3 1.500000 55.5000 37.0000
Subtotal (Total Children Is Unduplicated) 3 1.500000 55.5000 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 1 2.000000 111.0000 55.5000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 10 16.500000 1237.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 10 16.000000 1200.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 11 16.000000 1200.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 1 2.000000 111.0000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 36 59.500000 3302.2500 55.5000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 6 10.500000 787.5000 75.0000
Subtotal (Total Children Is Unduplicated) 48 126.500000 8249.2500 65.2115
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 2 2.000000 482.2300 241.1150
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 10 48.000000 2400.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 64 222.500000 11125.0000 50.0000
INTR-T1013-INTERPRETER 1 2.000000 150.0000 75.0000
OCCT-97530-OT SESSION BY LICENSED OT 8 16.000000 1143.0400 71.4400
OCCT-97530GT-OT SESSION BY LICENSED OT 20 85.250000 6090.2600 71.4400
OCCT-97530TLGT-OT SESSION BY LICENSED OT 2 2.000000 142.8800 71.4400
PHY-97110-PT SESSION BY LICENSED PT 10 56.500000 4036.3600 71.4400
PHY-97110GT-PT SESSION BY LICENSED PT 11 26.750000 1911.0200 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 21 71.500000 5107.9600 71.4400
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 33 150.000000 10775.5600 71.8371
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 1 4.000000 285.7600 71.4400
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 1 0.750000 53.5800 71.4400
Subtotal (Total Children Is Unduplicated) 148 687.250000 43703.6500 63.5921
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Total 815.250000 52008.4000 63.7944
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Number of Children (Unduplicated) With at Least One Service 180
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Center 53
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 0 0.000000 0.0000 0.0000
D 0 0.000000 0.0000 0.0000
S 12 14.000000 953.6400 0.0000
H 0 0.000000 0.0000 0.0000
T 33 34.000000 1735.2500 1735.2500
671 697.250000 44302.0300 0.0000
Other 70 70.000000 5017.4800 0.0000
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Total 786 815.250000 52008.4000 1735.2500