CMS/EIP Fiscal Report Center: 54
Services beginning 10/01/2021 ending 12/31/2021 Date of Report:02/04/2022 Page: 1
List order: No List
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 858 2947.750000 109057.5000 36.9969
Subtotal (Total Children Is Unduplicated) 858 2947.750000 109057.5000 36.9969
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 7 14.000000 1050.0000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 7 13.000000 975.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 4 8.000000 600.0000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 1 2.000000 150.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 4 7.500000 416.2500 55.5000
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 44 85.000000 6375.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 3 5.000000 375.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 55 105.000000 7875.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 35 70.000000 5250.0000 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 90 172.500000 9573.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 5 9.500000 712.5000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 42 83.500000 6262.5000 75.0000
SPCH-92523TLGT-EVAL OF SPCH SOUND PROD; EVAL LANG COM 2 2.000000 102.1000 51.0500
Subtotal (Total Children Is Unduplicated) 152 594.000000 40699.6000 68.5178
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 64 166.250000 8312.5000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 369 1825.750000 91287.5000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 12 33.000000 2357.5200 71.4400
OCCT-97530GT-OT SESSION BY LICENSED OT 24 99.000000 7072.5600 71.4400
OCCT-97530TL-OT SESSION BY LICENSED OT 9 22.500000 1607.4000 71.4400
OCCT-97530TLGT-OT SESSION BY LICENSED OT 47 145.500000 10394.5200 71.4400
PHY-97110-PT SESSION BY LICENSED PT 8 21.000000 1500.2400 71.4400
PHY-97110GT-PT SESSION BY LICENSED PT 12 39.500000 2821.8800 71.4400
PHY-97110TL-PT SESSION BY LICENSED PT 16 71.000000 5072.2400 71.4400
PHY-97110TLGT-PT SESSION BY LICENSED PT 33 102.000000 7286.8800 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 16 25.500000 1821.7200 71.4400
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 2 5.000000 357.2000 71.4400
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 9 19.000000 1357.3600 71.4400
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 41 192.250000 13734.3400 71.4400
Subtotal (Total Children Is Unduplicated) 537 2767.250000 154983.8600 56.0065
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Total 6309.000000 304740.9600 48.3026
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Number of Children (Unduplicated) With at Least One Service 886
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Center 54
Flag Claims Units Chgs Paid
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R 3 4.250000 157.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 3179 2678.000000 123228.4500 1959.2500
P 1644 1437.750000 66788.8100 66669.8400
D 14 13.750000 810.7800 0.0000
S 8 6.500000 240.5000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
1987 2066.250000 108775.5900 0.0000
Other 134 102.500000 4739.5800 0.0000
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Total 6969 6309.000000 304740.9600 68629.0900