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
Payclass Filters:MED
Eligibility Filter:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 1589 4667.500000 172697.5000 37.0000
Subtotal (Total Children Is Unduplicated) 1589 4667.500000 172697.5000 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 6 9.500000 712.5000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 6 9.500000 712.5000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 2 3.000000 225.0000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 2 3.500000 262.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 14 34.000000 2550.0000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 8 21.000000 1575.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 1.500000 83.2500 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 9 16.500000 915.7500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 4 6.500000 487.5000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 125 206.500000 15487.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 12 18.500000 1387.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 35 55.500000 4162.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 4 6.500000 487.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 19 30.500000 1692.7500 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 157 255.000000 14152.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 16 26.500000 1987.5000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 144 247.500000 18562.5000 75.0000
OCTH-97167-OT EVAL HIGH COMPLEXITY 1 1.000000 51.0500 51.0500
PSTH-97161-PT EVAL LOW COMPLEXITY 1 1.000000 51.0500 51.0500
SPCH-92523GT-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 1 1.000000 51.0500 51.0500
Subtotal (Total Children Is Unduplicated) 300 954.500000 65597.4000 68.7244
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 41 122.500000 6125.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 66 188.250000 9412.5000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 19 41.500000 2964.7600 71.4400
OCCT-97530GT-OT SESSION BY LICENSED OT 21 55.750000 3982.7800 71.4400
OCCT-97530TL-OT SESSION BY LICENSED OT 1 0.750000 53.5800 71.4400
PHY-97110-PT SESSION BY LICENSED PT 20 43.000000 3071.9200 71.4400
PHY-97110GT-PT SESSION BY LICENSED PT 18 46.750000 3339.8200 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 12 40.750000 2911.1800 71.4400
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 19 47.250000 3375.5400 71.4400
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 1 2.000000 142.8800 71.4400
Subtotal (Total Children Is Unduplicated) 156 588.500000 35379.9600 60.1189
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Total 6210.500000 273674.8600 44.0665
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Number of Children (Unduplicated) With at Least One Service 1596
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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 8 2.000000 74.0000 0.0000
P 1 1.000000 50.0000 50.0000
D 80 80.250000 4141.6900 0.0000
S 3688 2419.250000 109400.4200 0.0000
H 5670 3386.250000 139900.2500 125725.2500
T 1 0.250000 9.2500 0.0000
21 7.500000 277.5000 0.0000
Other 283 314.000000 19821.7500 0.0000
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Total 9752 6210.500000 273674.8600 125775.2500