CMS/EIP Fiscal Report Center: 53
Services beginning 07/01/2020 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 2252 10596.75000 391720.2500 36.9661
Subtotal (Total Children Is Unduplicated) 2252 10596.75000 391720.2500 36.9661
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 2 3.500000 262.5000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 21 39.500000 2962.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 3 4.500000 337.5000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 18 35.000000 2625.0000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 14 27.500000 2062.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 3 6.000000 450.0000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 12 24.000000 1800.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 6 10.500000 582.7500 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 26 47.000000 2553.0000 54.3191
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 20 38.500000 2887.5000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 263 496.000000 37200.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 31 54.500000 4087.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 203 380.000000 28500.0000 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 134 241.500000 18112.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 3 6.000000 333.0000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 459 848.000100 46971.5055 55.3909
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 3 6.000000 450.0000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 250 460.000000 34500.0000 75.0000
SCREEN-T1023-SCREENING 1 3.000000 150.0000 50.0000
Subtotal (Total Children Is Unduplicated) 804 2733.000100 186977.7555 68.4148
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EI Services,Class #03
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 5 5.500000 137.5000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 45 67.000000 3350.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 340 3177.000000 158850.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 12 25.000000 1786.0000 71.4400
OCCT-97530GT-OT SESSION BY LICENSED OT 14 93.500000 6679.6400 71.4400
OCCT-97530TL-OT SESSION BY LICENSED OT 2 3.000000 214.3200 71.4400
OCCT-97530TLGT-OT SESSION BY LICENSED OT 71 596.250000 42596.1000 71.4400
PHY-97110-PT SESSION BY LICENSED PT 7 11.000000 785.8400 71.4400
PHY-97110GT-PT SESSION BY LICENSED PT 4 6.500000 464.3600 71.4400
PHY-97110TL-PT SESSION BY LICENSED PT 2 8.000000 571.5200 71.4400
PHY-97110TLGT-PT SESSION BY LICENSED PT 52 503.750000 35987.9000 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 8 20.000000 1428.8000 71.4400
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 11 42.000000 3000.4800 71.4400
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 3 5.000000 357.2000 71.4400
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 82 734.500000 52393.6800 71.3324
SPL-92508TLGT-SPL THERAPY SESSION BY LICENSED SLP 1 1.000000 13.8800 13.8800
Subtotal (Total Children Is Unduplicated) 524 5299.000000 308617.2200 58.2407
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Total 18628.750100 887315.2255 47.6315
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Number of Children (Unduplicated) With at Least One Service 2264
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Center 53
Flag Claims Units Chgs Paid
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R 2556 2350.000000 112204.8400 0.0000
U 0 0.000000 0.0000 0.0000
B 3538 3175.250000 153343.9600 59.2500
P 14511 13103.500100 621766.4255 620550.7500
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 20605 18628.750100 887315.2255 620610.0000