CMS/EIP Fiscal Report Center: 09
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 1120 4114.250000 152208.7500 36.9955
Subtotal (Total Children Is Unduplicated) 1120 4114.250000 152208.7500 36.9955
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 8 15.500000 1162.5000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 5 10.000000 750.0000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 6 12.000000 900.0000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 2 4.000000 300.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 2.000000 111.0000 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 13 25.500000 1415.2500 55.5000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 136 256.500000 19237.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 65 123.500000 9262.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 60 113.500000 8512.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 3 6.000000 333.0000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 175 332.500000 18453.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 3 6.000000 450.0000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 31 59.000000 4425.0000 75.0000
OCTH-97166TLGT-OT EVAL MODERATE COMPLEXITY 2 2.000000 102.1000 51.0500
PSTF-97164-PT RE-EVAL EST PLAN CARE 2 2.000000 102.1000 51.0500
SPCH-92521-EVAL OF SPEECH FLUENCY 1 1.000000 51.0500 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 8 8.000000 408.4000 51.0500
SPCH-92523TLGT-EVAL OF SPCH SOUND PROD; EVAL LANG COM 2 2.000000 102.1000 51.0500
SPCH-92610-EVAL OF ORAL,PHARYNGEAL SWALLOWING FUNC 5 5.000000 222.7500 44.5500
Subtotal (Total Children Is Unduplicated) 249 986.000000 66301.5000 67.2429
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 617 4539.000000 226950.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 39 172.000000 8600.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 54 308.000000 21939.2000 71.2312
OCCT-97530GT-OT SESSION BY LICENSED OT 3 6.000000 428.6400 71.4400
OCCT-97530TLGT-OT SESSION BY LICENSED OT 4 23.750000 1696.7000 71.4400
PHY-97110-PT SESSION BY LICENSED PT 46 291.500000 20824.7600 71.4400
PHY-97110GT-PT SESSION BY LICENSED PT 12 83.000000 5929.5200 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 111 741.000000 52937.0400 71.4400
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 9 41.000000 2867.8800 69.9483
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 3 20.000000 1428.8000 71.4400
Subtotal (Total Children Is Unduplicated) 755 6225.250000 343602.5400 55.1950
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Total 11325.500000 562112.7900 49.6325
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Number of Children (Unduplicated) With at Least One Service 1201
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Center 09
Flag Claims Units Chgs Paid
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R 10 8.500000 314.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 1094 1172.000000 47238.7600 37.0000
P 3350 3466.750000 138566.8800 138566.5050
D 11 11.000000 550.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 9 7.750000 364.7500 729.5000
1847 6249.000000 348058.4000 0.0000
Other 228 410.500000 27019.5000 0.0000
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Total 6549 11325.500000 562112.7900 139333.0050