CMS/EIP Fiscal Report Center: 57
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 843 3677.750000 135429.2500 36.8239
Subtotal (Total Children Is Unduplicated) 843 3677.750000 135429.2500 36.8239
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 9 14.000000 1050.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 1.500000 112.5000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 5 8.500000 637.5000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 6 9.500000 712.5000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 8 12.000000 870.7500 72.5625
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 2 3.000000 166.5000 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 12 21.000000 1165.5000 55.5000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 135 210.500000 15690.0000 74.5368
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 32 51.500000 3810.0000 73.9806
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 1 1.500000 112.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 41 60.500000 4537.5000 75.0000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 176 275.500000 15290.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 1.500000 112.5000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 34 50.000000 3705.7500 74.1150
OCTH-97167-OT EVAL HIGH COMPLEXITY 6 6.000000 306.3000 51.0500
OCTH-97167GT-OT EVAL HIGH COMPLEXITY 1 1.000000 51.0500 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 1 1.000000 51.0500 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 6 6.000000 306.3000 51.0500
SPCH-92523GT-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 1 1.000000 51.0500 51.0500
Subtotal (Total Children Is Unduplicated) 244 735.500000 48739.5000 66.2672
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 643 5501.500000 275075.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 50 267.750000 13387.5000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 12 52.000000 3714.8800 71.4400
OCCT-97530GT-OT SESSION BY LICENSED OT 1 1.000000 71.4400 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 7 20.000000 1144.0000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 2 3.500000 250.0400 71.4400
PHY-97110GT-PT SESSION BY LICENSED PT 1 2.000000 142.8800 71.4400
PHY-97110HM-PT SESSION BY PT ASST 12 66.500000 3801.1400 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 11 41.750000 2982.6200 71.4400
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 6 25.500000 1458.6000 57.2000
Subtotal (Total Children Is Unduplicated) 688 5981.500000 302028.1000 50.4937
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Total 10394.750000 486196.8500 46.7733
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Number of Children (Unduplicated) With at Least One Service 979
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Center 57
Flag Claims Units Chgs Paid
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R 1 0.500000 18.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 780 1051.750000 45074.2500 0.0000
P 2303 3221.750000 133865.0000 133982.9000
D 0 0.000000 0.0000 0.0000
S 2 2.500000 163.5500 51.0500
H 0 0.000000 0.0000 0.0000
T 36 112.250000 3944.2500 2836.9500
1673 5996.000000 302761.3000 302770.8000
Other 6 10.000000 370.0000 0.0000
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Total 4801 10394.750000 486196.8500 439641.7000