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
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 935 3301.500000 122146.2500 36.9972
Subtotal (Total Children Is Unduplicated) 935 3301.500000 122146.2500 36.9972
-----------------------------------------------------------------------------------------------------------------------
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 12 22.000000 1650.0000 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 5 9.000000 675.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 2 4.000000 300.0000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 4 8.000000 600.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 5 9.000000 499.5000 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 9 17.000000 943.5000 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 3 5.000000 375.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 78 143.000000 10725.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 43 84.000000 6300.0000 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 117 219.500000 12182.2500 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 58 115.500000 8662.5000 75.0000
SPCH-92523TLGT-EVAL OF SPCH SOUND PROD; EVAL LANG COM 2 2.000000 102.1000 51.0500
Subtotal (Total Children Is Unduplicated) 205 772.500000 53063.3500 68.6904
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 64 166.250000 8312.5000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 369 1825.750000 91287.5000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 12 33.000000 2357.5200 71.4400
OCCT-97530GT-OT SESSION BY LICENSED OT 24 99.000000 7072.5600 71.4400
OCCT-97530TL-OT SESSION BY LICENSED OT 9 22.500000 1607.4000 71.4400
OCCT-97530TLGT-OT SESSION BY LICENSED OT 47 145.500000 10394.5200 71.4400
PHY-97110-PT SESSION BY LICENSED PT 8 21.000000 1500.2400 71.4400
PHY-97110GT-PT SESSION BY LICENSED PT 12 39.500000 2821.8800 71.4400
PHY-97110TL-PT SESSION BY LICENSED PT 16 71.000000 5072.2400 71.4400
PHY-97110TLGT-PT SESSION BY LICENSED PT 33 102.000000 7286.8800 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 16 25.500000 1821.7200 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 9 19.000000 1357.3600 71.4400
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 41 192.250000 13734.3400 71.4400
Subtotal (Total Children Is Unduplicated) 537 2767.250000 154983.8600 56.0065
-----------------------------------------------------------------------------------------------------------------------
Total 6841.250000 330193.4600 48.2651
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 964
-----------------------------------------------------------------------------------------------------------------------
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 15 15.750000 960.7800 0.0000
S 8 6.500000 240.5000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
2022 2118.000000 111836.8400 0.0000
Other 137 105.500000 4887.5800 0.0000
---------------------------------------------------------
Total 7414 6841.250000 330193.4600 75424.8400