CMS/EIP Fiscal Report Center: 53
Services beginning 07/01/2019 ending 06/30/2020 Date of Report:07/21/2020 Page: 1
List order: No List
Agency Filter:EXT
Payclass Filters:MED
Eligibility Filter:Part C (excluding not eligible)
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Screening, Eval, and Assessment,Class #02
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 7 9.500000 712.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 1.500000 112.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 8 15.000000 832.5000 55.5000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 22 36.500000 2737.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 4 8.000000 600.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 21 37.500000 2812.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 3 4.500000 337.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 150 278.500000 15456.7500 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 15 29.000000 1609.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 35 55.500000 4162.5000 75.0000
OCTF-97168-OT RE-EVAL EST PLAN CARE 1 1.000000 51.0500 51.0500
Subtotal (Total Children Is Unduplicated) 241 476.500000 29424.8000 61.7519
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 17 40.000000 1000.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 450 4555.250000 227712.5000 49.9890
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 200 851.250000 42562.5000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 18 130.500000 9322.9200 71.4400
OCCT-97530GT-OT SESSION BY LICENSED OT 2 9.000000 642.9600 71.4400
OCCT-97530TL-OT SESSION BY LICENSED OT 1 10.000000 714.4000 71.4400
OCCT-97530TLGT-OT SESSION BY LICENSED OT 10 29.250000 2089.6200 71.4400
PHY-97110-PT SESSION BY LICENSED PT 26 160.000000 11430.4000 71.4400
PHY-97110GT-PT SESSION BY LICENSED PT 9 15.000000 1071.6000 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 14 53.000000 3786.3200 71.4400
Subtotal (Total Children Is Unduplicated) 553 5853.250000 300333.2200 51.3105
-----------------------------------------------------------------------------------------------------------------------
Total 6329.750000 329758.0200 52.0965
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 657
-----------------------------------------------------------------------------------------------------------------------
Center 53
Flag Claims Units Chgs Paid
---------------------------------------------------------
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 1 1.000000 50.0000 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
6140 6328.750000 329708.0200 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 6141 6329.750000 329758.0200 0.0000