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
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-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 4 7.500000 562.5000 75.0000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 9 17.500000 971.2500 55.5000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 14 23.000000 1725.0000 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 11 19.000000 1425.0000 75.0000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 42 80.000000 4440.0000 55.5000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 2.000000 150.0000 75.0000
Subtotal (Total Children Is Unduplicated) 75 153.000000 9573.7500 62.5735
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 7 19.000000 950.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 212 1144.000000 57200.0000 50.0000
OCCT-97530GT-OT SESSION BY LICENSED OT 10 19.750000 1410.9400 71.4400
OCCT-97530TL-OT SESSION BY LICENSED OT 3 8.000000 571.5200 71.4400
OCCT-97530TLGT-OT SESSION BY LICENSED OT 3 6.000000 428.6400 71.4400
PHY-97110GT-PT SESSION BY LICENSED PT 10 31.000000 2214.6400 71.4400
Subtotal (Total Children Is Unduplicated) 237 1227.750000 62775.7400 51.1307
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Total 1380.750000 72349.4900 52.3987
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Number of Children (Unduplicated) With at Least One Service 295
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Center 53
Flag Claims Units Chgs Paid
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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 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
1312 1380.750000 72349.4900 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 1312 1380.750000 72349.4900 0.0000