CMS/EIP Fiscal Report Center: 03
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 770 2289.750000 84720.7500 37.0000
Subtotal (Total Children Is Unduplicated) 770 2289.750000 84720.7500 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 2 3.500000 262.5000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 3 5.500000 412.5000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 2 3.500000 262.5000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 1 2.000000 150.0000 75.0000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 2 3.500000 194.2500 55.5000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 41 73.000000 5475.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 35 56.500000 4237.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 3 5.500000 412.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 32 55.000000 4125.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 4 7.000000 388.5000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 31 52.500000 2913.7500 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 36 58.500000 4387.5000 75.0000
PSTH-97161-PT EVAL LOW COMPLEXITY 1 1.000000 51.0500 51.0500
SPCH-92522-EVAL OF SPCH SOUND PROD 1 1.000000 51.0500 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 1 1.000000 51.0500 51.0500
SPCH-92523TL-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 1 1.000000 51.0500 51.0500
SPCH-92523TLGT-EVAL OF SPCH SOUND PROD; EVAL LANG COM 2 2.000000 102.1000 51.0500
Subtotal (Total Children Is Unduplicated) 102 333.500000 23640.3000 70.8855
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 4 8.000000 400.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 71 88.500000 4425.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 1 5.500000 392.9200 71.4400
OCCT-97530TLGT-OT SESSION BY LICENSED OT 10 17.500000 1250.2000 71.4400
PHY-97110-PT SESSION BY LICENSED PT 7 11.000000 785.8400 71.4400
PHY-97110GT-PT SESSION BY LICENSED PT 2 2.000000 142.8800 71.4400
PHY-97110TL-PT SESSION BY LICENSED PT 9 14.000000 1000.1600 71.4400
PHY-97110TLGT-PT SESSION BY LICENSED PT 2 8.000000 571.5200 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 7 15.000000 1071.6000 71.4400
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 3 4.250000 303.6200 71.4400
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 5 17.250000 1232.3400 71.4400
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 10 27.000000 1928.8800 71.4400
Subtotal (Total Children Is Unduplicated) 122 218.000000 13504.9600 61.9494
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Total 2841.250000 121866.0100 42.8917
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Number of Children (Unduplicated) With at Least One Service 783
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Center 03
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 3664 2743.250000 116992.6700 0.0000
P 47 46.750000 2404.4400 2357.4400
D 53 33.750000 1248.7500 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
19 17.500000 1220.1500 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 3783 2841.250000 121866.0100 2357.4400