CMS/EIP Fiscal Report Center: 52
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 438 1338.000000 49182.2500 36.7580
Subtotal (Total Children Is Unduplicated) 438 1338.000000 49182.2500 36.7580
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 2 4.000000 300.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 2 4.000000 300.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 3 6.000000 333.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 81 159.000000 11925.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 1 1.500000 112.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 30 60.000000 4500.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 10 20.000000 1500.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 20 40.000000 3000.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 70 139.000000 7714.5000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 5 10.000000 555.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 2 4.000000 300.0000 75.0000
OCTH-97165GT-OT EVAL LOW COMPLEXITY 2 2.000000 102.1000 51.0500
OCTH-97165TL-OT EVAL LOW COMPLEXITY 2 2.000000 102.1000 51.0500
OCTH-97167TL-OT EVAL HIGH COMPLEXITY 2 2.000000 102.1000 51.0500
PSTH-97162TL-PT EVAL MODERATE COMPLEXITY 1 1.000000 51.0500 51.0500
PSTH-97163TL-PT EVAL HIGH COMPLEXITY 1 1.000000 51.0500 51.0500
SCREEN-T1023-SCREENING 17 17.000000 850.0000 50.0000
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 1 1.000000 51.0500 51.0500
SPCH-92523TL-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 7 7.000000 357.3500 51.0500
Subtotal (Total Children Is Unduplicated) 132 484.500000 32506.8000 67.0935
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 252 1230.250000 61437.5000 49.9390
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 13 18.250000 912.5000 50.0000
OCCT-97530TL-OT SESSION BY LICENSED OT 24 113.000000 8072.7200 71.4400
OCCT-97530TLHM-OT SESSION BY OT ASST 9 25.500000 1458.6000 57.2000
PHY-97110TL-PT SESSION BY LICENSED PT 25 80.250000 5733.0600 71.4400
PHY-97110TLGT-PT SESSION BY LICENSED PT 5 11.000000 785.8400 71.4400
PHY-97110TLHM-PT SESSION BY PT ASST 3 21.250000 1214.6500 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 1 1.000000 71.4400 71.4400
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 93 410.000000 29204.6400 71.2308
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 9 19.500000 1393.0800 71.4400
Subtotal (Total Children Is Unduplicated) 353 1930.000000 110284.0300 57.1420
-----------------------------------------------------------------------------------------------------------------------
Total 3752.500000 191973.0800 51.1587
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 555
-----------------------------------------------------------------------------------------------------------------------
Center 52
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 42 43.000000 2416.5200 0.0000
U 0 0.000000 0.0000 0.0000
B 576 633.750000 31148.8300 37.0000
P 1603 1695.250000 76555.1200 76317.0800
D 0 0.000000 0.0000 0.0000
S 33 39.750000 1706.6300 59.2500
H 2 1.250000 59.2500 9.2500
T 2 4.000000 200.0000 0.0000
714 1332.750000 79784.9800 0.0000
Other 4 2.750000 101.7500 0.0000
---------------------------------------------------------
Total 2976 3752.500000 191973.0800 76422.5800