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:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 975 2663.000000 98475.5000 36.9792
Subtotal (Total Children Is Unduplicated) 975 2663.000000 98475.5000 36.9792
-----------------------------------------------------------------------------------------------------------------------
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 12 22.500000 1687.5000 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 5 9.500000 712.5000 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 15 31.000000 1720.5000 55.5000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 76 145.500000 10912.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 10 17.500000 1312.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 70 132.000000 9900.0000 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 47 84.500000 6337.5000 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 157 336.000000 18648.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 2 4.000000 300.0000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 57 109.000000 8175.0000 75.0000
Subtotal (Total Children Is Unduplicated) 218 926.500000 62262.7500 67.2021
-----------------------------------------------------------------------------------------------------------------------
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 22 69.750000 4982.9400 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) 507 2603.500000 143135.4800 54.9781
-----------------------------------------------------------------------------------------------------------------------
Total 6193.000000 303873.7300 49.0673
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 1077
-----------------------------------------------------------------------------------------------------------------------
Center 53
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 25 22.000000 951.7600 0.0000
U 0 0.000000 0.0000 0.0000
B 2773 2543.000000 123295.2400 0.0000
P 2196 1953.000000 92973.6000 92973.6000
D 257 202.250000 9917.9400 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
1325 1402.250000 73665.9300 0.0000
Other 12 9.500000 388.5000 101.7500
---------------------------------------------------------
Total 6665 6193.000000 303873.7300 93075.3500