CMS/EIP Fiscal Report Center: 53
Services beginning 01/01/2021 ending 03/31/2021 Date of Report:05/04/2021 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 930 2476.000000 91556.5000 36.9776
Subtotal (Total Children Is Unduplicated) 930 2476.000000 91556.5000 36.9776
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 9 16.000000 1200.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 1.500000 112.5000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 5 10.000000 750.0000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 10 19.000000 1425.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 2.000000 150.0000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 4 8.000000 600.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 1.500000 83.2500 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 14 29.000000 1609.5000 55.5000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 69 132.000000 9900.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 8 14.000000 1050.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 61 116.000000 8700.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 41 74.500000 5587.5000 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 135 293.000000 16261.5000 55.5000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 46 88.000000 6600.0000 75.0000
Subtotal (Total Children Is Unduplicated) 187 808.500000 54290.2500 67.1494
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 17 31.500000 1575.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 385 1966.500000 98325.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 3 5.000000 357.2000 71.4400
OCCT-97530GT-OT SESSION BY LICENSED OT 21 68.750000 4911.5000 71.4400
OCCT-97530TL-OT SESSION BY LICENSED OT 3 8.000000 571.5200 71.4400
OCCT-97530TLGT-OT SESSION BY LICENSED OT 32 122.000000 8715.6800 71.4400
PHY-97110GT-PT SESSION BY LICENSED PT 12 33.500000 2393.2400 71.4400
PHY-97110TLGT-PT SESSION BY LICENSED PT 22 126.750000 9055.0200 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 3 5.000000 357.2000 71.4400
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 6 20.500000 1464.5200 71.4400
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 1 1.000000 71.4400 71.4400
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 40 214.000000 15266.7200 71.3398
Subtotal (Total Children Is Unduplicated) 506 2602.500000 143064.0400 54.9718
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Total 5887.000000 288910.7900 49.0761
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Number of Children (Unduplicated) With at Least One Service 1032
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Center 53
Flag Claims Units Chgs Paid
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R 20 15.500000 711.2600 0.0000
U 0 0.000000 0.0000 0.0000
B 2645 2398.000000 115641.7400 0.0000
P 2111 1860.250000 88710.3500 88710.3500
D 213 162.250000 8437.9400 0.0000
S 77 61.000000 2680.7600 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
1312 1380.750000 72349.4900 0.0000
Other 11 9.250000 379.2500 92.5000
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Total 6389 5887.000000 288910.7900 88802.8500