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
Payclass Filters:GR
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 482 1152.000000 42624.0000 37.0000
Subtotal (Total Children Is Unduplicated) 779 1381.000000 50893.5000 36.8526
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Screening, Eval, and Assessment,Class #02
EXIT-EXIT-EXIT ASSESSMENT 10 15.250000 762.5000 50.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 1.500000 112.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 2 4.000000 222.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 21 37.500000 2812.5000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 2 3.500000 262.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 4 7.500000 562.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 18 33.000000 2475.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 1 1.500000 112.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 61 122.500000 6798.7500 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 1 1.000000 55.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 27 48.000000 3600.0000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 4 7.000000 525.0000 75.0000
Subtotal (Total Children Is Unduplicated) 113 284.250000 18451.2500 64.9120
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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 40 68.750000 3437.5000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 42 46.250000 2312.5000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 1 2.000000 142.8800 71.4400
PHY-97110-PT SESSION BY LICENSED PT 5 26.000000 1857.4400 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 2 14.000000 1000.1600 71.4400
Subtotal (Total Children Is Unduplicated) 367 812.250000 19337.9800 23.8079
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Total 2477.500000 88682.7300 35.7952
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Number of Children (Unduplicated) With at Least One Service 936
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Center 03
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
3809 2472.500000 88314.8500 0.0000
Other 4 5.000000 367.8800 0.0000
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Total 3813 2477.500000 88682.7300 0.0000