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:TPIN
Eligibility Filter:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
CASE-CASE-NON-TCM CASE MANAGEMENT 1 0.500000 18.5000 37.0000
Subtotal (Total Children Is Unduplicated) 1 0.500000 18.5000 37.0000
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Screening, Eval, and Assessment,Class #02
EXIT-EXIT-EXIT ASSESSMENT 8 10.000000 500.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 2 4.000000 300.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 2 2.233733 167.5300 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 57 112.200000 8415.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 20 36.273866 2720.5400 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 20 40.000000 3000.0000 75.0000
OCTF-97168-OT RE-EVAL EST PLAN CARE 8 7.195886 367.3500 51.0500
OCTF-97168GT-OT RE-EVAL EST PLAN CARE 1 1.000000 51.0500 51.0500
OCTH-97165-OT EVAL LOW COMPLEXITY 1 1.000000 51.0500 51.0500
OCTH-97166-OT EVAL MODERATE COMPLEXITY 2 2.000000 102.1000 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 11 11.857199 605.3100 51.0500
OCTH-97167GT-OT EVAL HIGH COMPLEXITY 1 1.000000 51.0500 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 4 7.897159 403.1500 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 8 10.000000 510.5000 51.0500
SPCH-92523GT-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 1 1.000000 51.0500 51.0500
SPCH-92524-BEHAV & QUAL ANALYSIS OF VOICE AND RES 1 1.000000 51.0500 51.0500
Subtotal (Total Children Is Unduplicated) 104 252.657843 17646.7300 69.8444
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EI Services,Class #03
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 1 1.500000 37.5000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 2 2.000000 100.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 5 10.000000 100.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 26 190.461082 13606.5400 71.4400
OCCT-97530GT-OT SESSION BY LICENSED OT 2 6.199888 442.9200 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 41 298.165034 17055.0400 57.2000
OCCT-97530HMGT-OT SESSION BY OT ASST 5 27.750000 1587.3000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 11 119.610027 8566.3800 71.6192
PHY-97110HM-PT SESSION BY PT ASST 17 167.215181 9558.0200 57.1600
PHY-97110HMGT-PT SESSION BY LICENSED PT ASST 2 2.564556 146.5900 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 67 424.576833 30331.7700 71.4400
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 1 1.000000 71.4400 71.4400
TRAV-TRAVS-Travel by mile 3 42.000000 18.6800 0.4448
Subtotal (Total Children Is Unduplicated) 132 1293.042601 81622.1800 63.1241
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Total 1546.200444 99287.4100 64.2138
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Number of Children (Unduplicated) With at Least One Service 193
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Center 55
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 401 408.032475 26792.3500 26792.3500
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 103 148.000000 10666.9800 0.0000
T 0 0.000000 0.0000 0.0000
1005 990.167969 61828.0800 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 1509 1546.200444 99287.4100 26792.3500