CMS/EIP Fiscal Report Center: 54
Services beginning 10/01/2021 ending 12/31/2021 Date of Report:02/04/2022 Page: 1
List order: No List
Payclass Filters:MED
Bill Flag Filter:RBPU
Eligibility Filter:All
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 896 3171.000000 117317.7500 36.9971
Subtotal (Total Children Is Unduplicated) 896 3171.000000 117317.7500 36.9971
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 9 17.000000 1275.0000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 9 17.000000 1275.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 4 7.000000 525.0000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 3 6.000000 450.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 1.500000 83.2500 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 2 4.000000 222.0000 55.5000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 55 104.000000 7800.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 1 1.500000 112.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 58 104.000000 7800.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 38 72.000000 5400.0000 75.0000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 39 78.000000 4329.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 5 9.500000 712.5000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 51 101.500000 7612.5000 75.0000
SPCH-92523TLGT-EVAL OF SPCH SOUND PROD; EVAL LANG COM 2 2.000000 102.1000 51.0500
Subtotal (Total Children Is Unduplicated) 192 527.000000 37848.8500 71.8195
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 4 6.000000 300.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 96 321.250000 16062.5000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 1 5.000000 357.2000 71.4400
OCCT-97530GT-OT SESSION BY LICENSED OT 5 7.000000 500.0800 71.4400
OCCT-97530TL-OT SESSION BY LICENSED OT 8 20.500000 1464.5200 71.4400
OCCT-97530TLGT-OT SESSION BY LICENSED OT 42 125.000000 8930.0000 71.4400
PHY-97110-PT SESSION BY LICENSED PT 8 21.000000 1500.2400 71.4400
PHY-97110GT-PT SESSION BY LICENSED PT 4 6.500000 464.3600 71.4400
PHY-97110TL-PT SESSION BY LICENSED PT 16 71.000000 5072.2400 71.4400
PHY-97110TLGT-PT SESSION BY LICENSED PT 30 94.000000 6715.3600 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 16 23.500000 1678.8400 71.4400
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 2 5.000000 357.2000 71.4400
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 7 14.000000 1000.1600 71.4400
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 36 177.750000 12698.4600 71.4400
Subtotal (Total Children Is Unduplicated) 215 897.500000 57101.1600 63.6225
-----------------------------------------------------------------------------------------------------------------------
Total 4595.500000 212267.7600 46.1904
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 907
-----------------------------------------------------------------------------------------------------------------------
Center 54
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 3 4.250000 157.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 3476 3012.750000 138675.9500 2109.2500
P 1753 1578.500000 73434.5600 73315.5900
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 0 0.000000 0.0000 0.0000
0 0.000000 0.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 5232 4595.500000 212267.7600 75424.8400