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:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 883 2382.250000 88106.2500 36.9845
Subtotal (Total Children Is Unduplicated) 883 2382.250000 88106.2500 36.9845
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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 5 8.500000 637.5000 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 9 17.000000 943.5000 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 86 159.500000 11962.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 4 8.000000 600.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 68 128.000000 9600.0000 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 22 38.000000 2850.0000 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 87 160.000000 8880.0000 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 29 54.000000 4050.0000 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) 201 608.500000 42027.2500 69.0670
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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 5125.250000 251892.8200 49.1474
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Number of Children (Unduplicated) With at Least One Service 1022
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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 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
1126 1159.250000 59767.6400 0.0000
Other 66 60.500000 3332.4100 0.0000
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Total 5497 5125.250000 251892.8200 76266.2100