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: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 3 1.500000 55.5000 37.0000
Subtotal (Total Children Is Unduplicated) 3 1.500000 55.5000 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 1 2.000000 111.0000 55.5000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 9 15.500000 1162.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 5 8.500000 637.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 9 12.500000 937.5000 75.0000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 17 29.000000 1609.5000 55.5000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 6 10.500000 787.5000 75.0000
Subtotal (Total Children Is Unduplicated) 33 80.000000 5395.5000 67.4438
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 4 12.000000 600.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 28 90.000000 4500.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 8 16.000000 1143.0400 71.4400
OCCT-97530GT-OT SESSION BY LICENSED OT 20 85.250000 6090.2600 71.4400
OCCT-97530TLGT-OT SESSION BY LICENSED OT 2 2.000000 142.8800 71.4400
PHY-97110-PT SESSION BY LICENSED PT 10 56.500000 4036.3600 71.4400
PHY-97110GT-PT SESSION BY LICENSED PT 11 26.750000 1911.0200 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 21 71.500000 5107.9600 71.4400
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 33 150.000000 10775.5600 71.8371
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 1 4.000000 285.7600 71.4400
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 1 0.750000 53.5800 71.4400
Subtotal (Total Children Is Unduplicated) 106 514.750000 34646.4200 67.3073
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Total 596.250000 40097.4200 67.2493
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Number of Children (Unduplicated) With at Least One Service 130
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Center 53
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 12 14.000000 953.6400 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
503 512.250000 34126.3000 0.0000
Other 70 70.000000 5017.4800 0.0000
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Total 585 596.250000 40097.4200 0.0000