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
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 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 3 5.500000 412.5000 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-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 64 121.500000 9112.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 2 4.000000 300.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 49 95.500000 7162.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 10 18.500000 1387.5000 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 43 82.000000 4551.0000 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
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) 145 395.000000 27885.9000 70.5972
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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 15 26.000000 1300.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 138 604.750000 30237.5000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 15 31.750000 2268.2200 71.4400
OCCT-97530GT-OT SESSION BY LICENSED OT 7 13.500000 964.4400 71.4400
OCCT-97530TL-OT SESSION BY LICENSED OT 6 12.750000 910.8600 71.4400
OCCT-97530TLGT-OT SESSION BY LICENSED OT 39 97.000000 6929.6800 71.4400
PHY-97110-PT SESSION BY LICENSED PT 7 7.000000 500.0800 71.4400
PHY-97110GT-PT SESSION BY LICENSED PT 3 3.500000 250.0400 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) 278 1282.250000 78034.2200 60.8573
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Total 3835.500000 185738.3700 48.4261
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Number of Children (Unduplicated) With at Least One Service 912
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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
200 189.000000 9016.1900 0.0000
Other 66 60.500000 3332.4100 0.0000
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Total 4292 3835.500000 185738.3700 69171.2100