CMS/EIP Fiscal Report Center: 53
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 806 2043.750000 75554.0000 36.9683
Subtotal (Total Children Is Unduplicated) 806 2043.750000 75554.0000 36.9683
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 2.000000 150.0000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 1 2.000000 150.0000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 3 5.500000 412.5000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 2 3.000000 225.0000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 3 6.000000 450.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 5 9.500000 527.2500 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 5 8.500000 471.7500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 3 5.000000 375.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 86 147.500000 11062.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 2 3.000000 225.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 63 109.500000 8212.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 1 1.000000 75.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 48 76.500000 5737.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 9 13.500000 749.2500 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 121 205.000000 11377.5000 55.5000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 19 36.000000 2700.0000 75.0000
Subtotal (Total Children Is Unduplicated) 223 633.500000 42900.7500 67.7202
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 83 235.250000 11762.5000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 299 1233.250000 61662.5000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 1 2.000000 142.8800 71.4400
OCCT-97530GT-OT SESSION BY LICENSED OT 4 6.500000 464.3600 71.4400
OCCT-97530TL-OT SESSION BY LICENSED OT 21 87.500000 6251.0000 71.4400
OCCT-97530TLGT-OT SESSION BY LICENSED OT 37 95.000000 6786.8000 71.4400
PHY-97110-PT SESSION BY LICENSED PT 2 7.000000 500.0800 71.4400
PHY-97110GT-PT SESSION BY LICENSED PT 4 4.000000 285.7600 71.4400
PHY-97110TL-PT SESSION BY LICENSED PT 31 114.500000 8179.8800 71.4400
PHY-97110TLGT-PT SESSION BY LICENSED PT 27 56.000000 4000.6400 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 4 5.000000 357.2000 71.4400
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 2 2.000000 142.8800 71.4400
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 29 62.500000 4464.9600 71.4394
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 72 287.500000 20539.0000 71.4400
SPL-92508TLGT-SPL THERAPY SESSION BY LICENSED SLP 1 1.000000 13.8800 13.8800
Subtotal (Total Children Is Unduplicated) 499 2199.000000 125554.3200 57.0961
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Total 4876.250000 244009.0700 50.0403
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Number of Children (Unduplicated) With at Least One Service 931
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Center 53
Flag Claims Units Chgs Paid
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R 36 35.000000 1415.8800 0.0000
U 0 0.000000 0.0000 0.0000
B 1668 1578.500000 79670.1100 9.2500
P 743 728.500000 34954.0200 34954.0600
D 28 26.750000 1893.8000 0.0000
S 96 71.250000 3188.4500 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
2242 2193.500000 111668.7500 0.0000
Other 324 242.750000 11218.0600 0.0000
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Total 5137 4876.250000 244009.0700 34963.3100