CMS/EIP Fiscal Report Center: 53
Services beginning 10/01/2021 ending 12/31/2021 Date of Report:02/04/2022 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 712 1799.750000 66544.5000 36.9743
Subtotal (Total Children Is Unduplicated) 712 1799.750000 66544.5000 36.9743
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 2 4.000000 300.0000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 7 12.500000 937.5000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 8 13.500000 1012.5000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 1 2.000000 150.0000 75.0000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 6 11.500000 638.2500 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 62 107.000000 8025.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 4 6.500000 487.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 36 61.500000 4612.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 1 1.500000 112.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 12 17.000000 1275.0000 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 71 121.000000 6715.5000 55.5000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 30 53.500000 4012.5000 75.0000
Subtotal (Total Children Is Unduplicated) 173 417.000000 28652.2500 68.7104
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 29 79.250000 3962.5000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 145 524.250000 26212.5000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 10 15.000000 1071.6000 71.4400
OCCT-97530GT-OT SESSION BY LICENSED OT 3 4.500000 321.4800 71.4400
OCCT-97530TL-OT SESSION BY LICENSED OT 9 11.000000 785.8400 71.4400
OCCT-97530TLGT-OT SESSION BY LICENSED OT 30 89.000000 6358.1600 71.4400
PHY-97110-PT SESSION BY LICENSED PT 1 5.750000 410.7800 71.4400
PHY-97110GT-PT SESSION BY LICENSED PT 1 4.500000 321.4800 71.4400
PHY-97110TL-PT SESSION BY LICENSED PT 10 41.500000 2964.7600 71.4400
PHY-97110TLGT-PT SESSION BY LICENSED PT 16 43.000000 3071.9200 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 9 15.000000 1071.6000 71.4400
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 17 55.000000 3929.2000 71.4400
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 53 221.250000 15748.5400 71.1798
Subtotal (Total Children Is Unduplicated) 264 1109.000000 66230.3600 59.7208
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Total 3325.750000 161427.1100 48.5386
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Number of Children (Unduplicated) With at Least One Service 790
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Center 53
Flag Claims Units Chgs Paid
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R 34 31.750000 1588.0300 0.0000
U 0 0.000000 0.0000 0.0000
B 2051 1892.500000 93358.4400 1055.0000
P 1440 1401.500000 66480.6400 66462.1400
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 3525 3325.750000 161427.1100 67517.1400