CMS/EIP Fiscal Report Center: 57
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 783 3330.750000 123187.8000 36.9850
Subtotal (Total Children Is Unduplicated) 783 3330.750000 123187.8000 36.9850
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 6 9.500000 712.5000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 3 5.500000 412.5000 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 4 6.500000 487.5000 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 2 3.000000 166.5000 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 11 19.500000 1082.2500 55.5000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 124 208.500000 15608.2500 74.8597
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 48 88.000000 6522.0000 74.1136
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 1 1.500000 112.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 45 74.000000 5452.5000 73.6824
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 182 314.000000 17427.0000 55.5000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 31 52.000000 3773.2500 72.5625
OCTH-97165-OT EVAL LOW COMPLEXITY 1 1.000000 51.0500 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 5 5.000000 255.2500 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 5 5.000000 255.2500 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 6 6.000000 306.3000 51.0500
SPCH-92523GT-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 1 1.000000 51.0500 51.0500
SPCH-92610-EVAL OF ORAL,PHARYNGEAL SWALLOWING FUNC 1 1.000000 44.5500 44.5500
Subtotal (Total Children Is Unduplicated) 244 807.000000 53170.2000 65.8862
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 563 3741.000000 187050.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 46 197.500000 9875.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 3 7.000000 500.0800 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 1 1.000000 57.2000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 2 3.000000 214.3200 71.4400
PHY-97110GT-PT SESSION BY LICENSED PT 1 1.500000 107.1600 71.4400
PHY-97110HM-PT SESSION BY PT ASST 4 29.000000 1657.6400 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 2 5.000000 357.2000 71.4400
Subtotal (Total Children Is Unduplicated) 600 3985.000000 199818.6000 50.1427
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Total 8122.750000 376176.6000 46.3115
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Number of Children (Unduplicated) With at Least One Service 912
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Center 57
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 962 1516.750000 63268.2500 0.0000
P 1880 2572.500000 110943.0000 119185.7200
D 0 0.000000 0.0000 0.0000
S 1 1.500000 83.2500 83.2500
H 0 0.000000 0.0000 0.0000
T 7 8.000000 410.0000 79.9500
1140 4020.000000 201324.1000 200788.5500
Other 2 4.000000 148.0000 0.0000
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Total 3992 8122.750000 376176.6000 320137.4700