CMS/EIP Fiscal Report Center: 55
Services beginning 10/01/2021 ending 12/31/2021 Date of Report:02/04/2022 Page: 1
List order: No List
Payclass Filters:OTHER
Eligibility Filter:Part C (excluding not eligible)
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
CASE-CASE-NON-TCM CASE MANAGEMENT 1 0.250000 9.2500 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 37 73.250000 2710.2500 37.0000
Subtotal (Total Children Is Unduplicated) 37 73.500000 2719.5000 37.0000
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Screening, Eval, and Assessment,Class #02
EXIT-EXIT-EXIT ASSESSMENT 1 2.000000 100.0000 50.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 1 2.000000 150.0000 75.0000
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 7 14.000000 1050.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 6 12.000000 900.0000 75.0000
OCTF-97168-OT RE-EVAL EST PLAN CARE 2 2.000000 102.1000 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 3 3.000000 153.1500 51.0500
PSTF-97164-PT RE-EVAL EST PLAN CARE 2 2.000000 102.1000 51.0500
PSTH-97162-PT EVAL MODERATE COMPLEXITY 1 1.000000 51.0500 51.0500
Subtotal (Total Children Is Unduplicated) 18 44.000000 3019.4000 68.6227
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 6 22.000000 1100.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 17 92.500000 6608.2000 71.4400
OCCT-97530GT-OT SESSION BY LICENSED OT 2 4.000000 285.7600 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 8 34.000000 1944.8000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 11 68.000000 4857.9200 71.4400
PHY-97110HM-PT SESSION BY PT ASST 5 30.250000 1729.0900 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 30 160.750000 11483.9800 71.4400
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 5 16.750000 1196.6200 71.4400
Subtotal (Total Children Is Unduplicated) 64 428.250000 29206.3700 68.1993
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Total 545.750000 34945.2700 64.0316
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Number of Children (Unduplicated) With at Least One Service 86
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Center 55
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 362 369.500000 25486.4100 25486.4100
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
196 176.250000 9458.8600 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 558 545.750000 34945.2700 25486.4100