CMS/EIP Fiscal Report Center: 04
Services beginning 01/01/2022 ending 03/31/2022 Date of Report:04/16/2022 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 1200 5158.500000 190864.5000 37.0000
Subtotal (Total Children Is Unduplicated) 1200 5158.500000 190864.5000 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 6 7.000000 525.0000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 18 21.000000 1575.0000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 1 1.000000 75.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 1.000000 55.5000 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 18 22.000000 1221.0000 55.5000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 61 66.000000 4950.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 1 1.000000 75.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 152 179.000000 13425.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 2 3.000000 166.5000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 230 315.000000 17482.5000 55.5000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 74 81.500000 6112.5000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 19 19.000000 1365.7200 71.8800
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 1 1.000000 31.1700 31.1700
OCTH-97165-OT EVAL LOW COMPLEXITY 3 3.000000 153.1500 51.0500
OCTH-97166-OT EVAL MODERATE COMPLEXITY 2 2.000000 102.1000 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 9 9.000000 459.4500 51.0500
PSTH-97161-PT EVAL LOW COMPLEXITY 2 2.000000 102.1000 51.0500
PSTH-97162-PT EVAL MODERATE COMPLEXITY 1 1.000000 51.0500 51.0500
PSTH-97162GT-PT EVAL MODERATE COMPLEXITY 2 2.000000 102.1000 51.0500
PSTH-97162TLGT-PT EVAL MODERATE COMPLEXITY 1 1.000000 51.0500 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 4 4.000000 204.2000 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 1 1.000000 51.0500 51.0500
Subtotal (Total Children Is Unduplicated) 288 742.500000 48336.1400 65.0992
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 796 4899.000000 244950.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 44 150.500000 7525.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 19 65.500000 4679.3200 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 16 76.000000 4347.2000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 5 16.500000 1178.7600 71.4400
PHY-97110HM-PT SESSION BY PT ASST 16 115.000000 6573.4000 57.1600
PHY-97110TLGTHM-PT SESSION BY PT ASST 1 1.000000 57.1600 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 2 2.500000 178.6000 71.4400
Subtotal (Total Children Is Unduplicated) 854 5326.000000 269489.4400 50.5988
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Total 11227.000000 508690.0800 45.3095
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Number of Children (Unduplicated) With at Least One Service 1426
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Center 04
Flag Claims Units Chgs Paid
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R 12 16.000000 969.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 2792 4332.000000 171904.9400 0.0000
P 644 1122.750000 41586.7200 41551.0000
D 32 38.250000 1415.2500 0.0000
S 0 0.000000 0.0000 0.0000
H 1604 5350.500000 270729.9700 0.0000
T 0 0.000000 0.0000 0.0000
291 367.500000 22084.2000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 5375 11227.000000 508690.0800 41551.0000