CMS/EIP Fiscal Report Center: 04
Services beginning 10/01/2020 ending 12/31/2020 Date of Report:01/23/2021 Page: 1
List order: No List
Payclass Filters:MED
Bill Flag Filter:RBPU
Eligibility Filter:All
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 1125 5478.250000 202595.5000 36.9818
Subtotal (Total Children Is Unduplicated) 1125 5478.250000 202595.5000 36.9818
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 7 7.000000 525.0000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 12 13.000000 975.0000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 8 14.500000 1087.5000 75.0000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 18 21.500000 1193.2500 55.5000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 39 41.000000 3075.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 97 108.500000 8137.5000 75.0000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 146 187.000000 10378.5000 55.5000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 36 48.000000 3600.0000 75.0000
Subtotal (Total Children Is Unduplicated) 186 440.500000 28971.7500 65.7701
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1 2.000000 100.0000 50.0000
OCCT-97530HM-OT SESSION BY OT ASST 1 4.000000 228.8000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 1 2.000000 142.8800 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 1 3.000000 214.3200 71.4400
Subtotal (Total Children Is Unduplicated) 4 11.000000 686.0000 62.3636
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Total 5929.750000 232253.2500 39.1675
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Number of Children (Unduplicated) With at Least One Service 1130
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Center 04
Flag Claims Units Chgs Paid
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R 87 135.250000 5061.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 2518 4067.250000 159728.7500 0.0000
P 1044 1727.250000 67463.2500 66848.5000
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
0 0.000000 0.0000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 3649 5929.750000 232253.2500 66848.5000