CMS/EIP Fiscal Report Center: 57
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 723 2941.750000 108818.8500 36.9912
Subtotal (Total Children Is Unduplicated) 723 2941.750000 108818.8500 36.9912
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 5 8.000000 600.0000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 3 5.500000 412.5000 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 2 3.000000 225.0000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 2 4.000000 300.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 2 3.000000 166.5000 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 8 14.500000 804.7500 55.5000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 90 156.500000 11737.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 33 61.500000 4612.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 34 58.500000 4319.2500 73.8333
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 134 237.000000 13153.5000 55.5000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 22 39.500000 2835.7500 71.7911
OCTH-97165-OT EVAL LOW COMPLEXITY 1 1.000000 51.0500 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 5 5.000000 255.2500 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 5 5.000000 255.2500 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 6 6.000000 306.3000 51.0500
SPCH-92523GT-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 1 1.000000 51.0500 51.0500
SPCH-92610-EVAL OF ORAL,PHARYNGEAL SWALLOWING FUNC 1 1.000000 44.5500 44.5500
Subtotal (Total Children Is Unduplicated) 182 612.000000 40280.7000 65.8181
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 563 3741.000000 187050.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 46 197.500000 9875.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 3 7.000000 500.0800 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 1 1.000000 57.2000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 2 3.000000 214.3200 71.4400
PHY-97110GT-PT SESSION BY LICENSED PT 1 1.500000 107.1600 71.4400
PHY-97110HM-PT SESSION BY PT ASST 4 29.000000 1657.6400 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 2 5.000000 357.2000 71.4400
Subtotal (Total Children Is Unduplicated) 600 3985.000000 199818.6000 50.1427
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Total 7538.750000 348918.1500 46.2833
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Number of Children (Unduplicated) With at Least One Service 844
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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 850 1302.500000 53915.7500 0.0000
P 1683 2215.750000 93559.7500 101802.4700
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 5 4.250000 233.2500 59.6000
1138 4012.250000 201061.4000 200788.5500
Other 2 4.000000 148.0000 0.0000
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Total 3678 7538.750000 348918.1500 302650.6200