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
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 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
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 17 24.500000 1837.5000 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 29 48.500000 3637.5000 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 2 4.000000 222.0000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 41 64.500000 3579.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 4 7.000000 525.0000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 24 36.500000 2737.5000 75.0000
Subtotal (Total Children Is Unduplicated) 96 202.000000 13814.2500 68.3874
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 11 20.000000 1000.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 24 37.500000 1875.0000 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-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) 64 124.500000 7661.4800 61.5380
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Total 503.500000 28015.4800 55.6415
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Number of Children (Unduplicated) With at Least One Service 369
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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 0 0.000000 0.0000 0.0000
S 574 498.500000 27830.4800 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 3 3.250000 120.2500 0.0000
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Total 579 503.500000 28015.4800 0.0000