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
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 879 819.500000 30321.5000 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 1589 7050.500000 260868.5000 37.0000
Subtotal (Total Children Is Unduplicated) 1635 7870.000000 291190.0000 37.0000
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Screening, Eval, and Assessment,Class #02
EVAL-96111-DEVELOPMENTAL EVALUATION 17 14.750000 737.5000 50.0000
EXIT-EXIT-EXIT ASSESSMENT 55 39.750000 1987.5000 50.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 9 9.500000 712.5000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 22 25.500000 1912.5000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 7 7.500000 562.5000 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 26 35.500000 1970.2500 55.5000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 94 102.500000 7687.5000 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 198 235.000000 17625.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 4 8.000000 444.0000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 327 588.000000 32606.2500 55.4528
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 167 222.500000 16687.5000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 81 81.000000 11161.0400 137.7906
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 1 1.000000 31.1700 31.1700
NURS-T1001-NURSING ASSESSMENT 1 4.000000 200.0000 50.0000
OCTH-97165-OT EVAL LOW COMPLEXITY 6 6.000000 306.3000 51.0500
OCTH-97166-OT EVAL MODERATE COMPLEXITY 3 3.000000 153.1500 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 14 14.000000 714.7000 51.0500
PSTH-97161-PT EVAL LOW COMPLEXITY 4 4.000000 204.2000 51.0500
PSTH-97162-PT EVAL MODERATE COMPLEXITY 2 2.000000 102.1000 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 5 5.000000 255.2500 51.0500
SPCH-92521-EVAL OF SPEECH FLUENCY 4 4.000000 204.2000 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 5 5.000000 255.2500 51.0500
SPCH-92524-BEHAV & QUAL ANALYSIS OF VOICE AND RES 1 1.000000 51.0500 51.0500
Subtotal (Total Children Is Unduplicated) 473 1423.500000 96855.0600 68.0401
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 14 21.000000 1050.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 965 5939.000000 296950.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 56 207.500000 10375.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 945 5965.000000 59650.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 40 126.250000 9019.3000 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 21 103.000000 5891.6000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 22 61.500000 4309.5600 70.0741
PHY-97110HM-PT SESSION BY PT ASST 19 137.000000 7830.9200 57.1600
PHY-97110TLGTHM-PT SESSION BY PT ASST 1 1.000000 57.1600 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 37 98.000000 7001.1200 71.4400
Subtotal (Total Children Is Unduplicated) 1089 12659.25000 402134.6600 31.7661
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Total 21952.750000 790179.7200 35.9946
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Number of Children (Unduplicated) With at Least One Service 1903
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Center 04
Flag Claims Units Chgs Paid
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R 13 17.000000 1044.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 2922 4559.250000 181535.0700 0.0000
P 2817 8365.000000 166612.3800 163640.6200
D 34 42.000000 1554.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 1615 5378.500000 272573.1700 0.0000
T 0 0.000000 0.0000 0.0000
3252 3470.000000 158577.6400 0.0000
Other 61 121.000000 8283.4600 0.0000
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Total 10714 21952.750000 790179.7200 163640.6200