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:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 1229 5379.000000 199023.0000 37.0000
Subtotal (Total Children Is Unduplicated) 1229 5379.000000 199023.0000 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 8 8.500000 637.5000 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 20 24.000000 1332.0000 55.5000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 69 74.000000 5550.0000 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 162 191.500000 14362.5000 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 251 342.500000 19008.7500 55.5000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 82 91.000000 6825.0000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 20 20.000000 1437.6000 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) 311 804.500000 52407.7700 65.1433
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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 11509.500000 520920.2100 45.2600
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Number of Children (Unduplicated) With at Least One Service 1455
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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 2921 4558.750000 181516.5700 0.0000
P 662 1154.250000 42752.2200 42716.5000
D 34 42.000000 1554.0000 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
307 387.000000 23323.4500 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 5541 11509.500000 520920.2100 42716.5000