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: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 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 4 8.000000 600.0000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 6 11.500000 862.5000 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 6 11.500000 638.2500 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 48 93.000000 6975.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 30 55.500000 4162.5000 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 113 213.000000 11821.5000 55.5000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 46 86.000000 6450.0000 75.0000
Subtotal (Total Children Is Unduplicated) 179 655.500000 44716.5000 68.2174
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 10 12.500000 625.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 176 822.500000 41125.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 3 5.000000 357.2000 71.4400
OCCT-97530GT-OT SESSION BY LICENSED OT 11 49.000000 3500.5600 71.4400
OCCT-97530TLGT-OT SESSION BY LICENSED OT 29 116.000000 8287.0400 71.4400
PHY-97110GT-PT SESSION BY LICENSED PT 2 2.500000 178.6000 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) 275 1374.750000 80288.3000 58.4021
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Total 4506.250000 216561.3000 48.0580
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Number of Children (Unduplicated) With at Least One Service 975
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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
0 0.000000 0.0000 0.0000
Other 11 9.250000 379.2500 92.5000
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Total 5077 4506.250000 216561.3000 88802.8500