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:EIP DEI DEIP
Payclass Filters:TPIN
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 2 1.000000 37.0000 37.0000
Subtotal (Total Children Is Unduplicated) 2 1.000000 37.0000 37.0000
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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 2 4.000000 300.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 2 4.000000 300.0000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 4 8.500000 471.7500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 3 4.500000 337.5000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 61 114.500000 8775.0000 76.6376
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 30 57.000000 4275.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 2 4.000000 300.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 27 44.500000 3337.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 2 4.000000 222.0000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 67 123.000000 6818.2500 55.4329
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 2 3.000000 225.0000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 14 26.000000 1950.0000 75.0000
SPL-92526-TREATMENT OF SWALLOWING DYSFUNCTION 1 6.000000 315.4200 52.5700
Subtotal (Total Children Is Unduplicated) 145 413.000000 28377.4200 68.7105
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 25 119.000000 5950.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 57 342.500000 17125.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 25 108.750000 7769.1000 71.4400
OCCT-97530GT-OT SESSION BY LICENSED OT 30 213.500000 16049.4800 75.1732
OCCT-97530TL-OT SESSION BY LICENSED OT 1 8.000000 1014.3200 126.7900
OCCT-97530TLGT-OT SESSION BY LICENSED OT 3 2.750000 262.8800 95.5927
PHY-97110-PT SESSION BY LICENSED PT 19 225.750000 16127.5800 71.4400
PHY-97110GT-PT SESSION BY LICENSED PT 20 139.000000 9930.1600 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 50 313.450000 22393.5400 71.4421
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 64 550.030000 39353.9600 71.5488
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 1 1.000000 71.4400 71.4400
Subtotal (Total Children Is Unduplicated) 183 2023.730000 136047.4600 67.2261
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Total 2437.730000 164461.8800 67.4652
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Number of Children (Unduplicated) With at Least One Service 264
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Center 53
Flag Claims Units Chgs Paid
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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 19 17.480000 2748.8000 1769.5900
D 64 67.500000 4558.2800 0.0000
S 14 16.000000 1096.5200 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
1597 1710.250000 113640.1000 0.0000
Other 605 624.000000 42230.6800 0.0000
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Total 2299 2435.230000 164274.3800 1769.5900