CMS/EIP Fiscal Report Center: 03
Services beginning 10/01/2021 ending 12/31/2021 Date of Report:02/04/2022 Page: 1
List order: No List
Agency Filter:EIP DEI DEIP
Eligibility Filter:Part C (excluding not eligible)
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
CASE-CASE-NON-TCM CASE MANAGEMENT 438 223.500000 8269.5000 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 12 5.500000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 1168 2844.500000 105246.5000 37.0000
Subtotal (Total Children Is Unduplicated) 1196 3073.500000 113516.0000 36.9338
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
EXIT-EXIT-EXIT ASSESSMENT 10 15.250000 762.5000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 2 3.500000 262.5000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 1 1.500000 112.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 3 6.000000 450.0000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 1 1.500000 112.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 3 5.500000 412.5000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 1 1.500000 112.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 4 7.500000 562.5000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 1 1.500000 112.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 5 9.500000 527.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 119 219.000000 16425.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 7 12.500000 937.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 38 70.500000 5287.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 5 8.000000 600.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 124 226.500000 16987.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 9 15.000000 1125.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 127 247.000000 13708.5000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 10 17.500000 971.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 109 196.500000 14737.5000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 8 12.500000 937.5000 75.0000
OCTH-97165-OT EVAL LOW COMPLEXITY 4 4.000000 204.2000 51.0500
OCTH-97165GT-OT EVAL LOW COMPLEXITY 1 1.000000 51.0500 51.0500
OCTH-97165TL-OT EVAL LOW COMPLEXITY 2 2.000000 102.1000 51.0500
OCTH-97165TLGT-OT EVAL LOW COMPLEXITY 1 1.000000 51.0500 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 1 1.000000 51.0500 51.0500
PSTF-97164-PT RE-EVAL EST PLAN CARE 2 2.000000 102.1000 51.0500
PSTH-97161-PT EVAL LOW COMPLEXITY 4 4.000000 224.5900 56.1475
PSTH-97162-PT EVAL MODERATE COMPLEXITY 1 1.000000 51.0500 51.0500
PSTH-97162TL-PT EVAL MODERATE COMPLEXITY 2 2.000000 102.1000 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 10 10.000000 530.8900 53.0890
SPCH-92523TL-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 4 4.000000 204.2000 51.0500
SPCH-92610-EVAL OF ORAL,PHARYNGEAL SWALLOWING FUNC 1 1.000000 44.5500 44.5500
Subtotal (Total Children Is Unduplicated) 319 1111.250000 76863.4300 69.1684
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 11 14.250000 712.5000 50.0000
COIFF-COIFFGT-IFSP CONSULT,PROF,FACE TO FACE 46 36.500000 1825.0000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 1 1.000000 25.0000 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 70 89.500000 4475.0000 50.0000
CONIF-CONIFGT-CONSULT,ITDS,FACE TO FACE 59 71.000000 3550.0000 50.0000
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 264 443.000000 0.0000 0.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 82 169.250000 8462.5000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 128 133.250000 6662.5000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 11 50.000000 3572.0000 71.4400
OCCT-97530GT-OT SESSION BY LICENSED OT 5 7.750000 553.6600 71.4400
OCCT-97530TL-OT SESSION BY LICENSED OT 11 36.000000 2571.8400 71.4400
OCCT-97530TLGT-OT SESSION BY LICENSED OT 3 2.500000 178.6000 71.4400
PHY-97110-PT SESSION BY LICENSED PT 25 82.500000 5893.8000 71.4400
PHY-97110GT-PT SESSION BY LICENSED PT 2 2.000000 142.8800 71.4400
PHY-97110TL-PT SESSION BY LICENSED PT 22 49.750000 3554.1400 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 66 198.250000 14234.4200 71.8004
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 16 16.750000 1196.6200 71.4400
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 24 55.500000 3964.9200 71.4400
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 6 6.250000 388.9400 62.2304
Subtotal (Total Children Is Unduplicated) 473 1465.000000 61964.3200 42.2965
-----------------------------------------------------------------------------------------------------------------------
Total 5649.750000 252343.7500 44.6646
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 1271
-----------------------------------------------------------------------------------------------------------------------
Center 03
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 67 35.000000 1295.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 1725 1598.500000 80643.9000 0.0000
P 0 0.000000 0.0000 0.0000
D 2 2.000000 100.0000 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
4301 3079.000000 132179.8200 0.0000
Other 1418 935.250000 38125.0300 0.0000
---------------------------------------------------------
Total 7513 5649.750000 252343.7500 0.0000