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:TPIN
Eligibility Filter:Not Part C
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 1 3.250000 120.2500 37.0000
Subtotal (Total Children Is Unduplicated) 1 3.250000 120.2500 37.0000
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
EVAL-96111GT-DEVELOPMENTAL EVALUATION 1 2.000000 100.0000 50.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 1 1.500000 112.5000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 2 4.000000 300.0000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 1 1.500000 112.5000 75.0000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 2 4.000000 222.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 2 3.500000 262.5000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 15 26.000000 1950.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 19 30.500000 2287.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 7 11.500000 862.5000 75.0000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 33 57.000000 3191.2500 55.9868
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 1.500000 112.5000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 12 21.000000 1575.0000 75.0000
Subtotal (Total Children Is Unduplicated) 47 164.000000 11088.2500 67.6113
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 1 5.000000 250.0000 50.0000
PHY-97110GT-PT SESSION BY LICENSED PT 1 0.750000 53.5800 71.4400
Subtotal (Total Children Is Unduplicated) 2 5.750000 303.5800 52.7965
-----------------------------------------------------------------------------------------------------------------------
Total 173.000000 11512.0800 66.5438
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 49
-----------------------------------------------------------------------------------------------------------------------
Center 53
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 3 3.250000 120.2500 0.0000
P 0 0.000000 0.0000 0.0000
D 3 3.750000 249.3300 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 9 10.500000 584.5000 584.5000
78 132.500000 8891.5000 0.0000
Other 14 23.000000 1666.5000 0.0000
---------------------------------------------------------
Total 107 173.000000 11512.0800 584.5000