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
Agency Filter:EXT
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 3 3.500000 129.5000 37.0000
Subtotal (Total Children Is Unduplicated) 3 3.500000 129.5000 37.0000
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
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 2 3.500000 262.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 7 12.500000 693.7500 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 23 44.500000 2469.7500 55.5000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 3 5.000000 375.0000 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 64 116.000000 8700.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 12 20.500000 1537.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 29 47.000000 2608.5000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 190 330.500000 18342.7500 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 1 2.000000 150.0000 75.0000
Subtotal (Total Children Is Unduplicated) 329 586.500000 35514.7500 60.5537
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 255 1341.250000 67062.5000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 435 4620.000000 230987.0000 49.9972
OCCT-97530-OT SESSION BY LICENSED OT 13 31.250000 2232.5000 71.4400
OCCT-97530GT-OT SESSION BY LICENSED OT 7 16.750000 1196.6200 71.4400
OCCT-97530TL-OT SESSION BY LICENSED OT 12 47.500000 3393.4000 71.4400
OCCT-97530TLGT-OT SESSION BY LICENSED OT 22 192.000000 13716.4800 71.4400
PHY-97110-PT SESSION BY LICENSED PT 2 6.000000 428.6400 71.4400
PHY-97110GT-PT SESSION BY LICENSED PT 4 4.000000 285.7600 71.4400
Subtotal (Total Children Is Unduplicated) 544 6258.750000 319302.9000 51.0170
-----------------------------------------------------------------------------------------------------------------------
Total 6848.750000 354947.1500 51.8266
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 745
-----------------------------------------------------------------------------------------------------------------------
Center 53
Flag Claims Units Chgs Paid
---------------------------------------------------------
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 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
6669 6848.750000 354947.1500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 6669 6848.750000 354947.1500 0.0000