CMS/EIP Fiscal Report Center: 09
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: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 1040 3836.750000 141959.7500 37.0000
Subtotal (Total Children Is Unduplicated) 1040 3836.750000 141959.7500 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 2 3.500000 262.5000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 2 3.500000 262.5000 75.0000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 7 13.000000 721.5000 55.5000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 38 68.500000 5137.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 22 42.000000 3150.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 1 1.500000 112.5000 75.0000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 93 176.000000 9768.0000 55.5000
OCTH-97166TLGT-OT EVAL MODERATE COMPLEXITY 2 2.000000 102.1000 51.0500
SPCH-92523TLGT-EVAL OF SPCH SOUND PROD; EVAL LANG COM 1 1.000000 44.5500 44.5500
Subtotal (Total Children Is Unduplicated) 129 311.000000 19561.1500 62.8976
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 4 4.000000 200.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 28 125.000000 6250.0000 50.0000
OCCT-97530GT-OT SESSION BY LICENSED OT 1 2.000000 142.8800 71.4400
OCCT-97530TLGT-OT SESSION BY LICENSED OT 3 14.750000 1053.7400 71.4400
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 2 3.000000 214.3200 71.4400
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 4 16.000000 1071.6400 66.9775
SPL-92508TLGT-SPL THERAPY SESSION BY LICENSED SLP 1 1.000000 13.8800 13.8800
Subtotal (Total Children Is Unduplicated) 35 165.750000 8946.4600 53.9756
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Total 4313.500000 170467.3600 39.5195
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Number of Children (Unduplicated) With at Least One Service 1058
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Center 09
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 368 401.000000 16178.5700 166.5000
P 3765 3893.250000 153489.1200 153695.6220
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 5 6.000000 277.5000 527.2500
3 3.000000 142.9200 0.0000
Other 8 10.250000 379.2500 0.0000
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Total 4149 4313.500000 170467.3600 154389.3720