CMS/EIP Fiscal Report Center: 55
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:Part C (excluding not eligible)
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 655 1848.750000 68403.7500 37.0000
Subtotal (Total Children Is Unduplicated) 655 1848.750000 68403.7500 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 5 10.000000 750.0000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 2 4.000000 300.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 2.000000 111.0000 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 4 10.000000 555.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 1 2.000000 150.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 71 142.000000 10650.0000 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 17 33.926134 2544.4600 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 23 46.000000 3450.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 5 10.000000 555.0000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 33 66.000000 3663.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 2 6.000000 450.0000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 4 8.000000 600.0000 75.0000
OCTF-97168-OT RE-EVAL EST PLAN CARE 6 6.000000 306.3000 51.0500
OCTF-97168GT-OT RE-EVAL EST PLAN CARE 3 3.000000 153.1500 51.0500
OCTF-97168TL-OT RE-EVAL EST PLAN CARE 5 5.000000 255.2500 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 12 12.000000 612.6000 51.0500
OCTH-97167GT-OT EVAL HIGH COMPLEXITY 1 1.000000 51.0500 51.0500
OCTH-97167TL-OT EVAL HIGH COMPLEXITY 2 2.000000 102.1000 51.0500
PSTF-97164-PT RE-EVAL EST PLAN CARE 4 4.000000 204.2000 51.0500
PSTF-97164TL-PT RE-EVAL EST PLAN CARE 5 5.000000 255.2500 51.0500
PSTH-97162-PT EVAL MODERATE COMPLEXITY 1 1.000000 51.0500 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 2 2.000000 102.1000 51.0500
PSTH-97163TL-PT EVAL HIGH COMPLEXITY 1 1.000000 51.0500 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 8 8.000000 408.4000 51.0500
SPCH-92523GT-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 1 1.000000 51.0500 51.0500
SPCH-92523TL-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 4 4.000000 204.2000 51.0500
Subtotal (Total Children Is Unduplicated) 140 400.926134 27036.2100 67.4344
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EI Services,Class #03
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 1 2.250000 56.2500 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 211 1265.000000 63250.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 19 73.500000 3675.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 77 450.750000 32201.5800 71.4400
OCCT-97530GT-OT SESSION BY LICENSED OT 1 11.000000 785.8400 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 70 461.750000 26412.1000 57.2000
OCCT-97530HMGT-OT SESSION BY OT ASST 7 7.000000 400.4000 57.2000
OCCT-97530TL-OT SESSION BY LICENSED OT 17 89.000000 6358.1600 71.4400
OCCT-97530TLGTHM-OT SESSION BY OT ASST 3 21.000000 1201.2000 57.2000
OCCT-97530TLHM-OT SESSION BY OT ASST 34 304.000000 17388.8000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 36 229.000000 16359.7600 71.4400
PHY-97110GT-PT SESSION BY LICENSED PT 1 9.000000 642.9600 71.4400
PHY-97110HM-PT SESSION BY PT ASST 31 209.750000 11989.3100 57.1600
PHY-97110HMGT-PT SESSION BY LICENSED PT ASST 2 3.000000 171.4800 57.1600
PHY-97110TL-PT SESSION BY LICENSED PT 5 24.250000 1732.4200 71.4400
PHY-97110TLHM-PT SESSION BY PT ASST 12 101.250000 5787.4500 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 116 632.750000 45203.6600 71.4400
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 1 4.000000 285.7600 71.4400
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 62 404.000000 28861.7600 71.4400
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 3 18.000000 1285.9200 71.4400
SPL-92508HA-GROUP SPL SESSION PER CHILD 2 7.000000 97.1600 13.8800
Subtotal (Total Children Is Unduplicated) 466 4327.250000 264146.9700 61.0427
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Total 6576.926134 359586.9300 54.6740
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Number of Children (Unduplicated) With at Least One Service 707
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Center 55
Flag Claims Units Chgs Paid
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R 1 2.000000 150.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 2731 2180.500000 90573.4600 0.0000
P 4 7.750000 286.7500 286.7500
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
4309 4386.676134 268576.7200 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 7045 6576.926134 359586.9300 286.7500