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
Eligibility Filter:Not Part C
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
CASE-CASE-NON-TCM CASE MANAGEMENT 192 379.750000 14023.0000 36.9269
TCM-T1017TL-TARGETED CASE MANAGEMENT 223 1386.000000 51181.2500 36.9273
Subtotal (Total Children Is Unduplicated) 223 1765.750000 65204.2500 36.9272
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Screening, Eval, and Assessment,Class #02
EVAL-96111-DEVELOPMENTAL EVALUATION 2 3.000000 150.0000 50.0000
EVAL-96111GT-DEVELOPMENTAL EVALUATION 13 21.000000 1050.0000 50.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 3 5.500000 412.5000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 2 4.000000 300.0000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 4 7.000000 525.0000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 4 6.500000 487.5000 75.0000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 9 16.500000 915.7500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 5 9.000000 675.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 79 136.000000 10200.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 5 8.000000 600.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 73 122.000000 9111.0000 74.6803
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 1 1.500000 112.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 53 84.000000 6300.0000 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 164 305.500000 16983.0000 55.5908
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 3 5.500000 412.5000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 66 115.000000 8625.0000 75.0000
Subtotal (Total Children Is Unduplicated) 215 852.000000 56970.7500 66.8671
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EI Services,Class #03
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 1 6.000000 300.0000 50.0000
OCCT-97530GT-OT SESSION BY LICENSED OT 1 1.000000 71.4400 71.4400
PHY-97110GT-PT SESSION BY LICENSED PT 1 0.750000 53.5800 71.4400
Subtotal (Total Children Is Unduplicated) 3 7.750000 425.0200 54.8413
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Total 2625.500000 122600.0200 46.6959
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Number of Children (Unduplicated) With at Least One Service 223
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Center 53
Flag Claims Units Chgs Paid
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R 153 158.000000 7277.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 289 286.250000 13279.2500 0.0000
P 948 988.750100 46408.2555 46408.2900
D 24 25.000000 1404.3300 0.0000
S 7 10.000000 750.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 19 25.000000 1452.0000 1452.0000
1420 1109.249900 50353.4345 0.0000
Other 15 23.250000 1675.7500 9.2500
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Total 2875 2625.500000 122600.0200 47869.5400