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: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 2.000000 74.0000 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 13 33.750000 1248.7500 37.0000
Subtotal (Total Children Is Unduplicated) 13 35.750000 1322.7500 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 2 4.000000 300.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 1 2.000000 111.0000 55.5000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 21 40.500000 3037.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 19 37.500000 2812.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 6 11.000000 825.0000 75.0000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 23 43.500000 2414.2500 55.5000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 4 7.500000 562.5000 75.0000
Subtotal (Total Children Is Unduplicated) 48 150.000000 10362.7500 69.0850
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 1 1.000000 342.0000 342.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 9 26.000000 1300.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 59 216.000000 10800.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 16 34.000000 2428.9600 71.4400
OCCT-97530GT-OT SESSION BY LICENSED OT 27 97.250000 6947.5400 71.4400
OCCT-97530TLGT-OT SESSION BY LICENSED OT 2 3.000000 214.3200 71.4400
PHY-97110-PT SESSION BY LICENSED PT 10 24.750000 1768.1400 71.4400
PHY-97110GT-PT SESSION BY LICENSED PT 10 54.750000 3911.3400 71.4400
SENS-V5264-EARMOLD 1 1.000000 18.0000 18.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 13 28.000000 2000.3200 71.4400
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 41 171.000000 12269.8200 71.7533
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 1 2.000000 142.8800 71.4400
Subtotal (Total Children Is Unduplicated) 146 658.750000 42143.3200 63.9747
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Total 844.500000 53828.8200 63.7405
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Number of Children (Unduplicated) With at Least One Service 176
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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 0 0.000000 0.0000 0.0000
P 0 0.000000 0.0000 0.0000
D 2 4.000000 261.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 20 20.000000 1292.0000 1292.0000
739 794.750000 50436.2400 0.0000
Other 26 25.750000 1839.5800 0.0000
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Total 787 844.500000 53828.8200 1292.0000