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:TPIN
Eligibility Filter:Part C (excluding not eligible)
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 1 2.000000 150.0000 75.0000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 3 5.500000 255.2500 46.4091
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 20 36.500000 2552.5000 69.9315
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 10 18.500000 1233.1900 66.6589
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 2 4.000000 300.0000 75.0000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 49 95.500000 4975.2500 52.0969
PSTF-97164GT-PT RE-EVAL EST PLAN CARE 1 1.000000 51.0500 51.0500
Subtotal (Total Children Is Unduplicated) 72 163.000000 9517.2400 58.3880
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EI Services,Class #03
OCCT-97530GT-OT SESSION BY LICENSED OT 1 1.000000 71.4400 71.4400
OCCT-97530TLGT-OT SESSION BY LICENSED OT 1 2.000000 142.8800 71.4400
PHY-97110GT-PT SESSION BY LICENSED PT 1 4.000000 285.7600 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 1 1.000000 71.4400 71.4400
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 2 15.000000 871.6000 58.1067
Subtotal (Total Children Is Unduplicated) 5 23.000000 1443.1200 62.7443
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Total 186.000000 10960.3600 58.9267
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Number of Children (Unduplicated) With at Least One Service 75
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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 0 0.000000 0.0000 0.0000
P 51 87.500000 4725.7000 5091.0100
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 1 1.500000 33.2500 0.0000
56 95.000000 6090.4100 0.0000
Other 1 2.000000 111.0000 0.0000
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Total 109 186.000000 10960.3600 5091.0100