CMS/EIP Fiscal Report Center: 57
Services beginning 10/01/2021 ending 12/31/2021 Date of Report:02/04/2022 Page: 1
List order: No List
Eligibility Filter:Not Part C
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
CASE-CASE-NON-TCM CASE MANAGEMENT 44 23.750000 878.7500 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 144 989.500000 36482.0000 36.8691
Subtotal (Total Children Is Unduplicated) 147 1013.250000 37360.7500 36.8722
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 2 3.000000 225.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 2 3.500000 262.5000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 1 1.500000 112.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 2.000000 150.0000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 1 1.500000 112.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 1.500000 83.2500 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 3 5.000000 277.5000 55.5000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 64 98.500000 7189.2500 72.9873
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 18 26.500000 1937.5000 73.1132
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 23 29.500000 2112.5000 71.6102
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 92 137.500000 7453.7800 54.2093
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 16 21.000000 1495.7500 71.2262
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 1 1.000000 51.0500 51.0500
Subtotal (Total Children Is Unduplicated) 114 335.500000 21725.5800 64.7558
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1 20.000000 1000.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 2 26.000000 260.0000 10.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 1 5.000000 357.2000 71.4400
Subtotal (Total Children Is Unduplicated) 2 51.000000 1617.2000 31.7098
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Total 1399.750000 60703.5300 43.3674
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Number of Children (Unduplicated) With at Least One Service 147
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Center 57
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 55 96.250000 4619.5000 0.0000
P 233 453.000000 20193.2500 20356.2100
D 2 2.000000 130.5000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 31 84.250000 3071.0300 1927.2500
457 756.000000 32384.0000 0.0000
Other 4 8.250000 305.2500 0.0000
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Total 782 1399.750000 60703.5300 22283.4600