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
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 870 2271.250000 83944.7500 36.9597
Subtotal (Total Children Is Unduplicated) 870 2271.250000 83944.7500 36.9597
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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 2 4.000000 300.0000 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 2 4.000000 300.0000 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 1 2.000000 150.0000 75.0000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 8 15.500000 860.2500 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 34 64.000000 4800.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 7 10.500000 787.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 39 73.000000 5475.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 17 32.000000 2400.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 1 2.000000 111.0000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 107 215.500000 11904.7500 55.2425
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 54 103.500000 7762.5000 75.0000
SCREEN-T1023-SCREENING 1 3.000000 150.0000 50.0000
Subtotal (Total Children Is Unduplicated) 148 578.500000 38713.5000 66.9205
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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 24 40.500000 2025.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 302 1430.000000 71500.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 1 1.000000 71.4400 71.4400
OCCT-97530GT-OT SESSION BY LICENSED OT 13 20.750000 1482.3800 71.4400
OCCT-97530TLGT-OT SESSION BY LICENSED OT 50 223.500000 15966.8400 71.4400
PHY-97110GT-PT SESSION BY LICENSED PT 6 11.000000 785.8400 71.4400
PHY-97110TLGT-PT SESSION BY LICENSED PT 33 157.250000 11233.9400 71.4400
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 6 7.750000 553.6600 71.4400
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 41 226.250000 16163.3000 71.4400
Subtotal (Total Children Is Unduplicated) 430 2119.000000 119807.4000 56.5396
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Total 4968.750000 242465.6500 48.7981
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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 18 10.500000 414.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 3267 2886.500000 137832.3000 0.0000
P 1276 1124.250000 53993.6500 53984.4000
D 29 27.750000 1414.2000 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
813 858.000000 45384.0900 0.0000
Other 62 61.750000 3426.9100 9.2500
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Total 5465 4968.750000 242465.6500 53993.6500