CMS/EIP Fiscal Report Center: 52
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
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 8 18.500000 684.5000 37.0000
Subtotal (Total Children Is Unduplicated) 8 18.500000 684.5000 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 46 102.000000 6667.5000 65.3676
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 5 10.000000 750.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 25 56.000000 3735.0000 66.6964
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 5 12.000000 730.0000 60.8333
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 47 96.000000 5196.0000 54.1250
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 1 2.000000 111.0000 55.5000
SCREEN-T1023-SCREENING 5 5.000000 250.0000 50.0000
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 2 2.000000 102.1000 51.0500
Subtotal (Total Children Is Unduplicated) 59 285.000000 17541.6000 61.5495
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 69 365.000000 18225.0000 49.9315
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 2 3.750000 187.5000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 1 4.000000 80.0000 20.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 33 204.750000 11927.2300 58.2526
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 5 21.250000 1518.1000 71.4400
Subtotal (Total Children Is Unduplicated) 101 598.750000 31937.8300 53.3408
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Total 902.250000 50163.9300 55.5987
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Number of Children (Unduplicated) With at Least One Service 147
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Center 52
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 126 156.500000 8422.0100 6167.9900
D 200 215.500000 10965.0000 130.0000
S 1 2.000000 150.0000 130.0000
H 161 205.000000 13001.3200 35.0000
T 257 298.750000 16544.3400 11968.6500
15 24.000000 1062.7600 0.0000
Other 1 0.500000 18.5000 0.0000
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Total 761 902.250000 50163.9300 18431.6400