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
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 2103 9797.500000 362230.2500 36.9717
Subtotal (Total Children Is Unduplicated) 2103 9797.500000 362230.2500 36.9717
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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 23 43.000000 3225.0000 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 10 20.500000 1537.5000 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 9 19.000000 1425.0000 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 22 39.500000 2136.7500 54.0949
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 19 36.500000 2737.5000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 238 451.500000 33862.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 28 49.500000 3712.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 171 324.500000 24337.5000 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 113 207.000000 15525.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 2 4.000000 222.0000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 373 699.500000 38729.7500 55.3678
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 2.000000 150.0000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 206 382.500000 28687.5000 75.0000
SCREEN-T1023-SCREENING 1 3.000000 150.0000 50.0000
Subtotal (Total Children Is Unduplicated) 672 2343.500000 160846.2500 68.6351
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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 46 68.000000 3400.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 346 3198.500000 159925.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 12 25.000000 1786.0000 71.4400
OCCT-97530GT-OT SESSION BY LICENSED OT 17 105.500000 7536.9200 71.4400
OCCT-97530TL-OT SESSION BY LICENSED OT 2 3.000000 214.3200 71.4400
OCCT-97530TLGT-OT SESSION BY LICENSED OT 74 618.750000 44203.5000 71.4400
PHY-97110-PT SESSION BY LICENSED PT 7 11.000000 785.8400 71.4400
PHY-97110GT-PT SESSION BY LICENSED PT 5 30.500000 2178.9200 71.4400
PHY-97110TL-PT SESSION BY LICENSED PT 3 9.000000 642.9600 71.4400
PHY-97110TLGT-PT SESSION BY LICENSED PT 53 532.500000 38041.8000 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 8 21.000000 1500.2400 71.4400
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 13 46.000000 3250.5200 70.6635
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 9 25.000000 1786.0000 71.4400
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 101 893.500000 63752.6400 71.3516
SPL-92508TLGT-SPL THERAPY SESSION BY LICENSED SLP 1 1.000000 13.8800 13.8800
Subtotal (Total Children Is Unduplicated) 555 5593.750000 329156.0400 58.8435
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Total 17734.750000 852232.5400 48.0544
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Number of Children (Unduplicated) With at Least One Service 2114
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Center 53
Flag Claims Units Chgs Paid
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R 2403 2192.000000 104927.8400 0.0000
U 0 0.000000 0.0000 0.0000
B 3252 2892.250000 140184.9600 59.2500
P 13560 12108.750000 574986.1700 573882.9600
D 234 230.000000 13945.2800 0.0000
S 232 222.500000 13231.5200 0.0000
H 28 28.000000 1964.6000 0.0000
T 1 2.000000 74.0000 0.0000
29 28.250000 1251.2500 0.0000
Other 32 31.000000 1666.9200 229.2500
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Total 19771 17734.750000 852232.5400 574171.4600