CMS/EIP Fiscal Report Center: 06
Services beginning 10/01/2021 ending 12/31/2021 Date of Report:02/04/2022 Page: 1
List order: No List
Payclass Filters:MED
Eligibility Filter:Part C (excluding not eligible)
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 1207 2938.750000 108688.7500 36.9847
Subtotal (Total Children Is Unduplicated) 1207 2938.750000 108688.7500 36.9847
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 2 4.000000 222.0000 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 2 4.000000 222.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 8 12.500000 937.5000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 175 304.500000 22837.5000 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 40 72.000000 5400.0000 75.0000
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 49 89.000000 6675.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 7 11.000000 610.5000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 165 290.000000 16095.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 2.000000 150.0000 75.0000
Subtotal (Total Children Is Unduplicated) 228 797.500000 53787.0000 67.4445
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 710 4916.750000 245837.5000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 134 458.750000 22937.5000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 8 38.000000 2714.7200 71.4400
OCCT-97530GT-OT SESSION BY LICENSED OT 4 11.000000 785.8400 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 10 51.500000 2945.7800 57.1996
OCCT-97530HMGT-OT SESSION BY OT ASST 4 12.500000 715.0000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 16 68.500000 4893.6400 71.4400
PHY-97110GT-PT SESSION BY LICENSED PT 7 21.000000 1500.2400 71.4400
PHY-97110HM-PT SESSION BY PT ASST 8 23.500000 1343.2600 57.1600
PHY-97110HMGT-PT SESSION BY LICENSED PT ASST 1 1.500000 85.7400 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 27 118.000000 8429.9200 71.4400
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 18 86.500000 6179.5600 71.4400
Subtotal (Total Children Is Unduplicated) 816 5807.500000 298368.7000 51.3764
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Total 9543.750000 460844.4500 48.2876
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Number of Children (Unduplicated) With at Least One Service 1357
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Center 06
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
10852 9543.750000 460844.4500 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 10852 9543.750000 460844.4500 0.0000