CMS/EIP Fiscal Report Center: 53
Services beginning 07/01/2021 ending 06/30/2022 Date of Report:08/08/2022 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 1751 7755.250000 286907.2500 36.9952
Subtotal (Total Children Is Unduplicated) 1751 7755.250000 286907.2500 36.9952
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 5 9.500000 712.5000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 13 25.000000 1875.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 1.500000 112.5000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 12 21.000000 1575.0000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 3 6.000000 450.0000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 8 16.000000 1200.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 9 16.000000 888.0000 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 33 66.000000 3663.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 10 18.000000 1350.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 232 427.500000 32062.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 11 19.500000 1462.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 215 398.500000 29887.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 6 10.000000 750.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 121 203.500000 15262.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 35 56.500000 3135.7500 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 438 790.500000 43872.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 6 12.000000 900.0000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 80 147.500000 11062.5000 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) 681 2247.500000 150375.1500 66.9077
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 353 1779.250000 88962.5000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 690 6706.500000 335312.0000 49.9981
OCCT-97530-OT SESSION BY LICENSED OT 32 68.000000 4857.9200 71.4400
OCCT-97530GT-OT SESSION BY LICENSED OT 19 48.750000 3482.7000 71.4400
OCCT-97530TL-OT SESSION BY LICENSED OT 42 222.750000 15913.2600 71.4400
OCCT-97530TLGT-OT SESSION BY LICENSED OT 88 515.250000 36809.4600 71.4400
PHY-97110-PT SESSION BY LICENSED PT 14 43.750000 3125.5000 71.4400
PHY-97110GT-PT SESSION BY LICENSED PT 12 17.000000 1214.4800 71.4400
PHY-97110TL-PT SESSION BY LICENSED PT 55 342.250000 24450.3400 71.4400
PHY-97110TLGT-PT SESSION BY LICENSED PT 51 208.250000 14877.3800 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 17 29.000000 2071.7600 71.4400
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 11 13.000000 928.7200 71.4400
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 70 349.800000 24989.0000 71.4380
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 129 1014.250000 72400.4600 71.3832
Subtotal (Total Children Is Unduplicated) 1021 11357.80000 629395.4800 55.4153
-----------------------------------------------------------------------------------------------------------------------
Total 21360.550000 1066677.8800 49.9368
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 1806
-----------------------------------------------------------------------------------------------------------------------
Center 53
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 160 166.000000 9137.4100 710.7500
P 11670 10730.300000 522577.2900 522449.7500
D 230 216.500000 14792.0300 0.0000
S 310 198.250000 7824.1900 0.0000
H 142 121.500000 6185.6900 9.2500
T 0 0.000000 0.0000 0.0000
9913 9745.500000 497455.7700 0.0000
Other 247 182.500000 8705.5000 286.7500
---------------------------------------------------------
Total 22672 21360.550000 1066677.8800 523456.5000