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
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 836 2158.250000 79818.2500 36.9829
Subtotal (Total Children Is Unduplicated) 836 2158.250000 79818.2500 36.9829
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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 4 8.000000 600.0000 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 8 15.500000 860.2500 55.5000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 64 121.500000 9112.5000 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 53 102.000000 7650.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 17 30.000000 2250.0000 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 66 123.500000 6854.2500 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 21 40.000000 3000.0000 75.0000
OCTF-97168-OT RE-EVAL EST PLAN CARE 1 2.000000 102.1000 51.0500
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) 158 474.000000 32680.7500 68.9467
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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 31 54.250000 2712.5000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 310 1376.250000 68799.5000 49.9906
OCCT-97530-OT SESSION BY LICENSED OT 18 35.500000 2536.1200 71.4400
OCCT-97530GT-OT SESSION BY LICENSED OT 13 26.250000 1875.3000 71.4400
OCCT-97530TL-OT SESSION BY LICENSED OT 7 13.750000 982.3000 71.4400
OCCT-97530TLGT-OT SESSION BY LICENSED OT 50 120.000000 8572.8000 71.4400
PHY-97110-PT SESSION BY LICENSED PT 9 13.000000 928.7200 71.4400
PHY-97110GT-PT SESSION BY LICENSED PT 8 9.500000 678.6800 71.4400
PHY-97110TL-PT SESSION BY LICENSED PT 6 14.000000 1000.1600 71.4400
PHY-97110TLGT-PT SESSION BY LICENSED PT 26 83.500000 5965.2400 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 12 23.000000 1643.1200 71.4400
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 2 2.000000 142.8800 71.4400
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 19 57.500000 4107.8000 71.4400
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 69 305.000000 21789.2000 71.4400
Subtotal (Total Children Is Unduplicated) 465 2134.500000 121759.3200 57.0435
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Total 4766.750000 234258.3200 49.1442
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Number of Children (Unduplicated) With at Least One Service 975
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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 2275 2031.250000 97916.9400 74.0000
P 1655 1458.750000 69454.4100 69097.2100
D 65 65.000000 4468.4200 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
1102 1120.250000 57536.1400 0.0000
Other 66 60.500000 3332.4100 0.0000
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Total 5194 4766.750000 234258.3200 69171.2100