CMS/EIP Fiscal Report Center: 53
Services beginning 04/01/2021 ending 06/30/2021 Date of Report:07/15/2021 Page: 1
List order: No List
Payclass Filters:MED
Bill Flag Filter:RBPU
Eligibility Filter:All
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 1011 2721.250000 100566.2500 36.9559
Subtotal (Total Children Is Unduplicated) 1011 2721.250000 100566.2500 36.9559
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 8 16.000000 1200.0000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 8 16.000000 1200.0000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 2 3.000000 225.0000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 6 11.000000 825.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 3 5.000000 277.5000 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 8 15.000000 832.5000 55.5000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 83 153.500000 11512.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 6 11.000000 825.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 56 101.500000 7612.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 41 71.500000 5362.5000 75.0000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 126 227.500000 12589.2500 55.3374
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 59 107.500000 8062.5000 75.0000
Subtotal (Total Children Is Unduplicated) 213 738.500000 50524.2500 68.4147
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EI Services,Class #03
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 2 3.000000 75.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 21 31.500000 1575.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 188 830.000000 41500.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 11 20.000000 1428.8000 71.4400
OCCT-97530GT-OT SESSION BY LICENSED OT 10 37.000000 2643.2800 71.4400
OCCT-97530TL-OT SESSION BY LICENSED OT 1 2.000000 142.8800 71.4400
OCCT-97530TLGT-OT SESSION BY LICENSED OT 38 130.000000 9287.2000 71.4400
PHY-97110-PT SESSION BY LICENSED PT 7 11.000000 785.8400 71.4400
PHY-97110TL-PT SESSION BY LICENSED PT 2 8.000000 571.5200 71.4400
PHY-97110TLGT-PT SESSION BY LICENSED PT 25 134.500000 9608.6800 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 7 15.000000 1071.6000 71.4400
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 2 4.750000 339.3400 71.4400
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 2 4.000000 285.7600 71.4400
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 48 188.000000 13373.1600 71.1338
Subtotal (Total Children Is Unduplicated) 302 1418.750000 82688.0600 58.2823
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Total 4878.500000 233778.5600 47.9202
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Number of Children (Unduplicated) With at Least One Service 1068
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Center 53
Flag Claims Units Chgs Paid
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R 2467 2237.000000 107346.8400 0.0000
U 0 0.000000 0.0000 0.0000
B 1756 1520.750000 73390.1800 0.0000
P 1203 1120.750000 53041.5400 53041.5400
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
0 0.000000 0.0000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 5426 4878.500000 233778.5600 53041.5400