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:TPIN
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 2 0.750000 27.7500 37.0000
Subtotal (Total Children Is Unduplicated) 2 0.750000 27.7500 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 2 4.000000 300.0000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 1 2.000000 150.0000 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 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 58 119.500000 8730.6500 73.0598
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 1 2.000000 150.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 37 78.000000 5510.0000 70.6410
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 6 11.000000 825.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 15 32.000000 2230.0000 69.6875
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 5 14.000000 708.2000 50.5857
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 57 114.000000 6327.0000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 2 4.000000 222.0000 55.5000
OCTH-97165-OT EVAL LOW COMPLEXITY 1 1.000000 51.0500 51.0500
OCTH-97165GT-OT EVAL LOW COMPLEXITY 1 1.000000 51.0500 51.0500
OCTH-97166-OT EVAL MODERATE COMPLEXITY 2 2.000000 102.1000 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 1 1.000000 51.0500 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 3 3.000000 153.1500 51.0500
SCREEN-T1023-SCREENING 8 9.000000 400.0000 44.4444
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 7 7.000000 357.3500 51.0500
Subtotal (Total Children Is Unduplicated) 107 416.500000 27101.6000 65.0699
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 1 1.000000 50.0000 50.0000
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 1 1.000000 50.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 138 688.500000 34085.0000 49.5062
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 10 10.000000 500.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 1 3.000000 30.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 16 44.250000 3161.2200 71.4400
OCCT-97530GT-OT SESSION BY LICENSED OT 9 16.500000 1178.7600 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 9 32.000000 1830.4000 57.2000
OCCT-97530HMGT-OT SESSION BY OT ASST 1 1.000000 57.2000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 21 73.750000 5268.7000 71.4400
PHY-97110GT-PT SESSION BY LICENSED PT 6 7.000000 500.0800 71.4400
PHY-97110HM-PT SESSION BY PT ASST 5 28.000000 1600.4800 57.1600
PHY-97110HMGT-PT SESSION BY LICENSED PT ASST 2 5.000000 285.8000 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 110 584.750000 38998.9800 66.6934
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 9 20.750000 1482.3800 71.4400
TRAV-TRAVS-Travel by mile 1 77.000000 34.2600 0.4449
Subtotal (Total Children Is Unduplicated) 255 1593.500000 89113.2600 55.9230
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Total 2010.750000 116242.6100 57.8106
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Number of Children (Unduplicated) With at Least One Service 317
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Center 52
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 0 0.000000 0.0000 0.0000
P 53 76.500000 3738.0600 2599.4600
D 175 197.250000 10154.5000 0.0000
S 0 0.000000 0.0000 0.0000
H 92 119.500000 7522.5000 37.5000
T 475 799.000000 43058.9500 38729.3500
470 818.500000 51768.6000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 1265 2010.750000 116242.6100 41366.3100