CMS/EIP Fiscal Report Center: 53
Services beginning 07/01/2020 ending 09/30/2020 Date of Report:10/15/2020 Page: 1
List order: No List
Payclass Filters:MED
Bill Flag Filter:RBPU
Eligibility Filter:All
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 907 2428.000000 89744.5000 36.9623
Subtotal (Total Children Is Unduplicated) 907 2428.000000 89744.5000 36.9623
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 2 3.500000 262.5000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 1 2.000000 150.0000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 5 9.500000 712.5000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 3 6.000000 450.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 2 4.000000 300.0000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 2 3.500000 262.5000 75.0000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 6 11.000000 610.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 17 32.500000 2437.5000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 38 70.000000 5250.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 6 9.000000 675.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 32 60.500000 4537.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 15 27.000000 2025.0000 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 99 181.500000 10017.7500 55.1942
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 68 128.500000 9637.5000 75.0000
SCREEN-T1023-SCREENING 1 3.000000 150.0000 50.0000
Subtotal (Total Children Is Unduplicated) 177 555.500000 37700.2500 67.8672
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EI Services,Class #03
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 2 1.000000 25.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 10 13.000000 650.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 149 764.000000 38200.0000 50.0000
OCCT-97530GT-OT SESSION BY LICENSED OT 3 4.000000 285.7600 71.4400
OCCT-97530TLGT-OT SESSION BY LICENSED OT 39 194.250000 13877.2200 71.4400
PHY-97110TLGT-PT SESSION BY LICENSED PT 31 145.000000 10358.8000 71.4400
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 5 6.750000 482.2200 71.4400
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 41 211.250000 15091.7000 71.4400
Subtotal (Total Children Is Unduplicated) 256 1339.250000 78970.7000 58.9664
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Total 4322.750000 206415.4500 47.7510
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Number of Children (Unduplicated) With at Least One Service 951
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Center 53
Flag Claims Units Chgs Paid
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R 19 10.750000 423.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 3469 3093.500000 147584.8000 0.0000
P 1372 1218.500000 58406.9000 58397.6500
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 0 0.000000 0.0000 0.0000
0 0.000000 0.0000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 4860 4322.750000 206415.4500 58397.6500