CMS/EIP Fiscal Report Center: 01
Services beginning 01/01/2022 ending 03/31/2022 Date of Report:04/16/2022 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 238 177.000000 6539.7500 36.9477
Subtotal (Total Children Is Unduplicated) 238 177.000000 6539.7500 36.9477
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 1.500000 112.5000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 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 5.500000 305.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 2 3.500000 262.5000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 36 56.500000 4237.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 4 8.000000 600.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 30 50.000000 3750.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 10 18.500000 1026.7500 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 88 140.500000 7797.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 7 12.500000 937.5000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 37 61.000000 4575.0000 75.0000
Subtotal (Total Children Is Unduplicated) 116 364.500000 24100.5000 66.1193
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 40 128.000000 6400.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 27 49.500000 2475.0000 50.0000
OCCT-97530TL-OT SESSION BY LICENSED OT 5 6.000000 428.6400 71.4400
OCCT-97530TLGT-OT SESSION BY LICENSED OT 8 15.500000 1107.3200 71.4400
PHY-97110TL-PT SESSION BY LICENSED PT 8 15.000000 1071.6000 71.4400
PHY-97110TLGT-PT SESSION BY LICENSED PT 9 15.500000 1107.3200 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 1 5.000000 357.2000 71.4400
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 2 2.000000 142.8800 71.4400
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 8 10.000000 714.4000 71.4400
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 3 5.000000 357.2000 71.4400
Subtotal (Total Children Is Unduplicated) 96 251.500000 14161.5600 56.3084
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Total 793.000000 44801.8100 56.4966
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Number of Children (Unduplicated) With at Least One Service 406
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Center 01
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 138 147.500000 7745.0800 0.0000
S 576 501.500000 28026.2300 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
2 1.750000 64.7500 0.0000
Other 87 142.250000 8965.7500 0.0000
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Total 803 793.000000 44801.8100 0.0000