CMS/EIP Fiscal Report Center: 06
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 1205 3244.000000 120009.5000 36.9943
Subtotal (Total Children Is Unduplicated) 1205 3244.000000 120009.5000 36.9943
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 4 7.000000 525.0000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 4 6.000000 450.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 2 4.000000 300.0000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 3 4.500000 337.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 3 5.000000 277.5000 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 4 6.500000 360.7500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 46 84.000000 6300.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 191 319.500000 23933.2500 74.9085
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 24 42.500000 3187.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 127 211.000000 15825.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 16 26.000000 1950.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 59 100.500000 7537.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 42 75.500000 4190.2500 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 170 294.000000 16317.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 2.000000 150.0000 75.0000
Subtotal (Total Children Is Unduplicated) 350 1192.000000 81941.2500 68.7427
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 703 4496.000000 224800.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 142 426.000000 21220.0000 49.8122
OCCT-97530-OT SESSION BY LICENSED OT 8 29.500000 2107.4800 71.4400
OCCT-97530GT-OT SESSION BY LICENSED OT 3 6.500000 464.3600 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 6 29.000000 1601.6000 55.2276
OCCT-97530HMGT-OT SESSION BY OT ASST 1 2.500000 143.0000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 12 48.500000 3464.8400 71.4400
PHY-97110GT-PT SESSION BY LICENSED PT 4 9.000000 642.9600 71.4400
PHY-97110HM-PT SESSION BY PT ASST 9 27.500000 1571.9000 57.1600
PHY-97110HMGT-PT SESSION BY LICENSED PT ASST 4 4.500000 257.2200 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 27 80.500000 5750.9200 71.4400
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 21 66.500000 4750.7600 71.4400
Subtotal (Total Children Is Unduplicated) 815 5226.000000 266775.0400 51.0477
-----------------------------------------------------------------------------------------------------------------------
Total 9662.000000 468725.7900 48.5123
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 1382
-----------------------------------------------------------------------------------------------------------------------
Center 06
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 0 0.000000 0.0000 0.0000
P 0 0.000000 0.0000 0.0000
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
10565 9661.000000 468688.7900 0.0000
Other 2 1.000000 37.0000 0.0000
---------------------------------------------------------
Total 10567 9662.000000 468725.7900 0.0000