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:OTHER
Eligibility Filter:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
CASE-CASE-NON-TCM CASE MANAGEMENT 5 1.500000 55.5000 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 281 977.250000 36158.2500 37.0000
Subtotal (Total Children Is Unduplicated) 281 978.750000 36213.7500 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 1 2.000000 111.0000 55.5000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 31 58.000000 4350.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 7 13.000000 975.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 7 13.000000 975.0000 75.0000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 32 59.500000 3302.2500 55.5000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 4 7.500000 562.5000 75.0000
OCTH-97165-OT EVAL LOW COMPLEXITY 1 1.000000 51.0500 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 1 1.000000 51.0500 51.0500
Subtotal (Total Children Is Unduplicated) 44 157.000000 10527.8500 67.0564
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EI Services,Class #03
CONPP-CONPP-CONSULT, PT, PHONE 1 1.000000 25.0000 25.0000
CONSF-CONSFGT-CONSULT,SLP,FACE TO FACE 1 1.000000 50.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1 5.000000 250.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 2 6.000000 60.0000 10.0000
PHY-97110HM-PT SESSION BY PT ASST 1 2.500000 142.9000 57.1600
Subtotal (Total Children Is Unduplicated) 5 15.500000 527.9000 34.0581
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Total 1151.250000 47269.5000 41.0593
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Number of Children (Unduplicated) With at Least One Service 293
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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 0 0.000000 0.0000 0.0000
P 0 0.000000 0.0000 0.0000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
594 1134.750000 46699.1500 142.9000
Other 8 16.500000 570.3500 487.1000
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Total 602 1151.250000 47269.5000 630.0000