CMS/EIP Fiscal Report Center: 01
Services beginning 10/01/2020 ending 12/31/2020 Date of Report:01/23/2021 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
Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 1 2.000000 150.0000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 3 5.500000 412.5000 75.0000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 3 4.000000 222.0000 55.5000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 42 78.500000 5887.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 11 20.500000 1137.7500 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 43 68.000000 3774.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 2 3.500000 262.5000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 34 53.000000 3975.0000 75.0000
Subtotal (Total Children Is Unduplicated) 137 235.000000 15821.2500 67.3245
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 23 58.000000 2900.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 7 16.000000 800.0000 50.0000
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 1 1.000000 71.4400 71.4400
Subtotal (Total Children Is Unduplicated) 29 75.000000 3771.4400 50.2859
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Total 310.000000 19592.6900 63.2022
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Number of Children (Unduplicated) With at Least One Service 164
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Center 01
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 1 1.000000 50.0000 50.0000
D 79 80.000000 4132.4400 0.0000
S 1 1.500000 83.2500 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 134 227.500000 15327.0000 0.0000
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Total 215 310.000000 19592.6900 50.0000