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
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 969 2469.500000 91297.7500 36.9701
Subtotal (Total Children Is Unduplicated) 969 2469.500000 91297.7500 36.9701
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 10 19.500000 1462.5000 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 1 1.500000 112.5000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 4 7.500000 562.5000 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 6 11.500000 638.2500 55.5000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 78 145.000000 10875.0000 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 43 80.000000 6000.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 35 63.500000 4762.5000 75.0000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 93 175.500000 9703.2500 55.2892
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 47 88.000000 6600.0000 75.0000
Subtotal (Total Children Is Unduplicated) 173 624.000000 43019.0000 68.9407
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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 22 32.500000 1625.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 191 843.000000 42150.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 11 20.000000 1428.8000 71.4400
OCCT-97530GT-OT SESSION BY LICENSED OT 11 40.000000 2857.6000 71.4400
OCCT-97530TL-OT SESSION BY LICENSED OT 1 2.000000 142.8800 71.4400
OCCT-97530TLGT-OT SESSION BY LICENSED OT 39 131.000000 9358.6400 71.4400
PHY-97110-PT SESSION BY LICENSED PT 7 11.000000 785.8400 71.4400
PHY-97110TL-PT SESSION BY LICENSED PT 3 9.000000 642.9600 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 16.000000 1143.0400 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 8 24.000000 1714.5600 71.4400
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 67 281.000000 20017.0800 71.2352
Subtotal (Total Children Is Unduplicated) 326 1551.750000 91889.4200 59.2166
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Total 4645.250000 226206.1700 48.6962
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Number of Children (Unduplicated) With at Least One Service 1021
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Center 53
Flag Claims Units Chgs Paid
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R 2317 2083.500000 100236.3400 0.0000
U 0 0.000000 0.0000 0.0000
B 1562 1324.750000 64236.9300 0.0000
P 1093 993.500000 46791.0400 46791.0400
D 32 34.500000 2123.1800 0.0000
S 157 164.000000 10682.2600 0.0000
H 0 0.000000 0.0000 0.0000
T 1 2.000000 74.0000 0.0000
29 28.250000 1251.2500 0.0000
Other 14 14.750000 811.1700 0.0000
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Total 5205 4645.250000 226206.1700 46791.0400