CMS/EIP Fiscal Report Center: 53
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 776 1834.500000 67858.0000 36.9899
Subtotal (Total Children Is Unduplicated) 776 1834.500000 67858.0000 36.9899
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 2.000000 150.0000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 5 9.500000 712.5000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 6 10.000000 750.0000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 1 2.000000 150.0000 75.0000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 5 10.000000 555.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 2 3.500000 262.5000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 49 86.000000 6450.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 4 6.500000 487.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 36 63.500000 4762.5000 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 25 37.500000 2812.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 1 2.000000 111.0000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 63 110.000000 6105.0000 55.5000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 26 46.500000 3487.5000 75.0000
Subtotal (Total Children Is Unduplicated) 154 392.500000 27058.5000 68.9389
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 35 132.250000 6612.5000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 145 542.000000 27100.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 10 16.000000 1143.0400 71.4400
OCCT-97530GT-OT SESSION BY LICENSED OT 4 5.500000 392.9200 71.4400
OCCT-97530TL-OT SESSION BY LICENSED OT 12 16.000000 1143.0400 71.4400
OCCT-97530TLGT-OT SESSION BY LICENSED OT 35 116.000000 8287.0400 71.4400
PHY-97110-PT SESSION BY LICENSED PT 1 5.750000 410.7800 71.4400
PHY-97110GT-PT SESSION BY LICENSED PT 1 4.500000 321.4800 71.4400
PHY-97110TL-PT SESSION BY LICENSED PT 25 81.500000 5822.3600 71.4400
PHY-97110TLGT-PT SESSION BY LICENSED PT 19 47.000000 3357.6800 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 9 15.000000 1071.6000 71.4400
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 21 78.000000 5572.3200 71.4400
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 60 256.750000 18284.6600 71.2158
SPL-92508TLGT-SPL THERAPY SESSION BY LICENSED SLP 1 1.000000 13.8800 13.8800
Subtotal (Total Children Is Unduplicated) 294 1317.250000 79533.3000 60.3783
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Total 3544.250000 174449.8000 49.2205
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Number of Children (Unduplicated) With at Least One Service 841
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Center 53
Flag Claims Units Chgs Paid
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R 34 31.750000 1588.0300 0.0000
U 0 0.000000 0.0000 0.0000
B 1937 1766.250000 87334.6900 1055.0000
P 1312 1254.500000 59858.8900 59840.3900
D 46 46.250000 3311.2200 0.0000
S 144 116.000000 6764.4800 1554.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
226 213.750000 9614.9100 0.0000
Other 148 115.750000 5977.5800 0.0000
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Total 3847 3544.250000 174449.8000 62449.3900