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:TPIN
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 1.000000 75.0000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 9 10.000000 750.0000 75.0000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 1 1.500000 83.2500 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 2 4.500000 249.7500 55.5000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 51 61.000000 4545.7500 74.5205
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 13 13.000000 3952.0000 304.0000
OCTF-97168-OT RE-EVAL EST PLAN CARE 1 1.000000 51.0500 51.0500
OCTH-97166-OT EVAL MODERATE COMPLEXITY 2 2.000000 102.1000 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 8 8.000000 408.4000 51.0500
PSTH-97162-PT EVAL MODERATE COMPLEXITY 4 4.000000 204.2000 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 2 2.000000 102.1000 51.0500
SPCH-92521-EVAL OF SPEECH FLUENCY 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 3 3.000000 153.1500 51.0500
Subtotal (Total Children Is Unduplicated) 73 113.000000 10778.8500 95.3881
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 3 22.000000 1100.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 25 119.000000 8451.3600 71.0198
OCCT-97530GT-OT SESSION BY LICENSED OT 2 8.000000 571.5200 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 11 46.500000 2659.8000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 16 97.500000 6843.0400 70.1850
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 17 90.500000 5763.7200 63.6875
Subtotal (Total Children Is Unduplicated) 55 383.500000 25389.4400 66.2045
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Total 496.500000 36168.2900 72.8465
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Number of Children (Unduplicated) With at Least One Service 110
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Center 04
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 77 185.000000 12097.7600 7734.7100
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 6 22.000000 1100.0000 0.0000
T 0 0.000000 0.0000 0.0000
82 91.000000 9655.7500 0.0000
Other 82 198.500000 13314.7800 857.2800
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Total 247 496.500000 36168.2900 8591.9900