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:TPIN
Eligibility Filter:Part C (excluding not eligible)
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
CASE-CASE-NON-TCM CASE MANAGEMENT 1 0.500000 18.5000 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 44 127.000000 4699.0000 37.0000
Subtotal (Total Children Is Unduplicated) 45 127.500000 4717.5000 37.0000
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Screening, Eval, and Assessment,Class #02
ASTE-ASTE-ASSISTIVE TECHNOLOGY EVAL 2 2.000000 97.0000 48.5000
EVAL-96111GT-DEVELOPMENTAL EVALUATION 1 2.000000 100.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 2.000000 150.0000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 2 4.000000 300.0000 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 1 1.500000 112.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 2 4.000000 300.0000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 3 5.000000 375.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 2.000000 111.0000 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 6 12.000000 666.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 4 8.000000 600.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 68 129.000000 9675.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 9 15.000000 1125.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 60 113.500000 8812.5000 77.6432
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 28 51.500000 3862.5000 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 100 188.000000 10662.0000 56.7128
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 46 88.000000 6600.0000 75.0000
Subtotal (Total Children Is Unduplicated) 188 633.500000 43959.5000 69.3915
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EI Services,Class #03
CONOF-CONOFGT-CONSULT,OT,FACE TO FACE 2 2.000000 100.0000 50.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 1 2.000000 50.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 9 15.250000 762.5000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 71 661.750000 33087.5000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 12 17.000000 1214.4800 71.4400
OCCT-97530GT-OT SESSION BY LICENSED OT 37 365.250000 26691.9400 73.0785
OCCT-97530TLGT-OT SESSION BY LICENSED OT 1 7.000000 500.0800 71.4400
PHY-97110-PT SESSION BY LICENSED PT 4 27.750000 2063.0200 74.3431
PHY-97110GT-PT SESSION BY LICENSED PT 19 297.250000 23351.3000 78.5578
PHY-97110TLGT-PT SESSION BY LICENSED PT 1 0.750000 53.5800 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 8 23.000000 1643.1200 71.4400
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 61 506.750000 36219.5700 71.4742
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 2 4.000000 285.7600 71.4400
Subtotal (Total Children Is Unduplicated) 182 1929.750000 126022.8500 65.3053
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Total 2690.750000 174699.8500 64.9261
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Number of Children (Unduplicated) With at Least One Service 296
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Center 53
Flag Claims Units Chgs Paid
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R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 37 38.750000 1433.7500 0.0000
P 60 51.660000 7091.5100 5805.5600
D 225 217.590000 14505.3300 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
1566 1808.500000 113641.5200 83.2500
Other 539 574.250000 38027.7400 0.0000
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Total 2427 2690.750000 174699.8500 5888.8100