CMS/EIP Fiscal Report Center: 53
Services beginning 07/01/2021 ending 09/30/2021 Date of Report:10/13/2021 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 847 2230.000000 82473.0000 36.9834
Subtotal (Total Children Is Unduplicated) 847 2230.000000 82473.0000 36.9834
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Screening, Eval, and Assessment,Class #02
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 5 9.500000 712.5000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 4 7.000000 525.0000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 4 8.000000 600.0000 75.0000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 1 1.500000 83.2500 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 77 141.500000 10612.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 3 6.000000 450.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 53 101.500000 7612.5000 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 13 23.000000 1725.0000 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 48 89.500000 4967.2500 55.5000
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 27 50.000000 3750.0000 75.0000
SPCH-92522GT-EVAL OF SPCH SOUND PROD 1 1.000000 51.0500 51.0500
SPCH-92523TL-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 1 2.000000 102.1000 51.0500
Subtotal (Total Children Is Unduplicated) 169 453.500000 32127.1500 70.8427
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EI Services,Class #03
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 1 1.000000 25.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 13 22.000000 1100.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 136 579.000000 28950.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 14 28.750000 2053.9000 71.4400
OCCT-97530GT-OT SESSION BY LICENSED OT 6 12.500000 893.0000 71.4400
OCCT-97530TL-OT SESSION BY LICENSED OT 4 7.000000 500.0800 71.4400
OCCT-97530TLGT-OT SESSION BY LICENSED OT 39 88.750000 6340.3000 71.4400
PHY-97110-PT SESSION BY LICENSED PT 6 6.000000 428.6400 71.4400
PHY-97110GT-PT SESSION BY LICENSED PT 2 1.500000 107.1600 71.4400
PHY-97110TL-PT SESSION BY LICENSED PT 4 8.000000 571.5200 71.4400
PHY-97110TLGT-PT SESSION BY LICENSED PT 24 76.500000 5465.1600 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 8 17.000000 1214.4800 71.4400
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 1 1.000000 71.4400 71.4400
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 15 48.000000 3429.1200 71.4400
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 64 260.000000 18574.4000 71.4400
Subtotal (Total Children Is Unduplicated) 266 1157.000000 69724.2000 60.2629
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Total 3840.500000 184324.3500 47.9949
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Number of Children (Unduplicated) With at Least One Service 925
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Center 53
Flag Claims Units Chgs Paid
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R 31 31.000000 1550.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 2434 2211.250000 106224.9400 74.0000
P 1775 1598.250000 76549.4100 76192.2100
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 4240 3840.500000 184324.3500 76266.2100