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
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 857 2947.500000 109048.2500 36.9969
Subtotal (Total Children Is Unduplicated) 857 2947.500000 109048.2500 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 6 11.000000 825.0000 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 3 6.000000 450.0000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 1 2.000000 150.0000 75.0000
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 1 1.500000 112.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 37 69.000000 5175.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 31 60.000000 4500.0000 75.0000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 29 58.000000 3219.0000 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 39 77.500000 5812.5000 75.0000
SPCH-92523TLGT-EVAL OF SPCH SOUND PROD; EVAL LANG COM 2 2.000000 102.1000 51.0500
Subtotal (Total Children Is Unduplicated) 141 397.500000 28633.6000 72.0342
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 4 6.000000 300.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 101 368.000000 18400.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 1 5.000000 357.2000 71.4400
OCCT-97530GT-OT SESSION BY LICENSED OT 5 7.000000 500.0800 71.4400
OCCT-97530TL-OT SESSION BY LICENSED OT 8 20.500000 1464.5200 71.4400
OCCT-97530TLGT-OT SESSION BY LICENSED OT 44 131.500000 9394.3600 71.4400
PHY-97110-PT SESSION BY LICENSED PT 8 21.000000 1500.2400 71.4400
PHY-97110GT-PT SESSION BY LICENSED PT 4 6.500000 464.3600 71.4400
PHY-97110TL-PT SESSION BY LICENSED PT 16 71.000000 5072.2400 71.4400
PHY-97110TLGT-PT SESSION BY LICENSED PT 31 96.000000 6858.2400 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) 226 974.250000 61581.8600 63.2095
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Total 4319.250000 199263.7100 46.1339
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Number of Children (Unduplicated) With at Least One Service 867
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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
76 76.500000 3298.3400 0.0000
Other 134 102.500000 4739.5800 0.0000
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Total 5058 4319.250000 199263.7100 68629.0900