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
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 870 2271.250000 83944.7500 36.9597
Subtotal (Total Children Is Unduplicated) 870 2271.250000 83944.7500 36.9597
-----------------------------------------------------------------------------------------------------------------------
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 4 7.500000 416.2500 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 5 7.500000 562.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 32 61.000000 4575.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 10 19.000000 1425.0000 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 78 146.000000 8047.5000 55.1199
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 53 101.500000 7612.5000 75.0000
SCREEN-T1023-SCREENING 1 3.000000 150.0000 50.0000
Subtotal (Total Children Is Unduplicated) 144 471.000000 32162.2500 68.2850
-----------------------------------------------------------------------------------------------------------------------
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 150 769.000000 38450.0000 50.0000
OCCT-97530GT-OT SESSION BY LICENSED OT 3 4.000000 285.7600 71.4400
OCCT-97530TLGT-OT SESSION BY LICENSED OT 39 197.250000 14091.5400 71.4400
PHY-97110TLGT-PT SESSION BY LICENSED PT 31 151.250000 10805.3000 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) 257 1369.500000 81024.5600 59.1636
-----------------------------------------------------------------------------------------------------------------------
Total 4111.750000 197131.5600 47.9435
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 913
-----------------------------------------------------------------------------------------------------------------------
Center 53
Flag Claims Units Chgs Paid
---------------------------------------------------------
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
1 1.000000 50.0000 0.0000
Other 62 61.750000 3426.9100 9.2500
---------------------------------------------------------
Total 4653 4111.750000 197131.5600 53993.6500