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:GR
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 376 1671.500000 61845.5000 37.0000
Subtotal (Total Children Is Unduplicated) 1070 2491.000000 92167.0000 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 1 1.000000 75.0000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 4 4.500000 337.5000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 1 1.500000 112.5000 75.0000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 12 11.500000 638.2500 55.5000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 24 27.500000 2062.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 35 42.500000 3187.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 2 5.000000 277.5000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 195 241.000000 13347.7500 55.3849
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 62 73.500000 5512.5000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 38 38.000000 2731.4400 71.8800
NURS-T1001-NURSING ASSESSMENT 1 4.000000 200.0000 50.0000
OCTH-97165-OT EVAL LOW COMPLEXITY 1 1.000000 51.0500 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 3 3.000000 153.1500 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 1 1.000000 51.0500 51.0500
Subtotal (Total Children Is Unduplicated) 317 509.500000 31462.6900 61.7521
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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 168 1035.000000 51750.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 11 56.000000 2800.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 945 5965.000000 59650.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 5 17.250000 1232.3400 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 3 20.000000 1144.0000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 1 3.000000 214.3200 71.4400
PHY-97110HM-PT SESSION BY PT ASST 2 16.000000 914.5600 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 1 3.000000 214.3200 71.4400
Subtotal (Total Children Is Unduplicated) 980 7136.250000 118969.5400 16.6712
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Total 10136.750000 242599.2300 23.9326
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Number of Children (Unduplicated) With at Least One Service 1660
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Center 04
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 1 0.500000 18.5000 0.0000
P 2120 7145.750000 119443.2900 119283.2900
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
2859 2990.500000 123137.4400 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 4980 10136.750000 242599.2300 119283.2900