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
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 1168 5970.750000 220818.0000 36.9833
Subtotal (Total Children Is Unduplicated) 1168 5970.750000 220818.0000 36.9833
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 11 12.000000 900.0000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 17 19.500000 1462.5000 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 24 28.000000 1554.0000 55.5000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 62 66.000000 4950.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 148 165.000000 12375.0000 75.0000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 230 294.500000 16344.7500 55.5000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 71 90.500000 6787.5000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 15 15.000000 883.6500 58.9100
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 3 3.000000 70.2600 23.4200
OCTH-97167-OT EVAL HIGH COMPLEXITY 7 7.000000 357.3500 51.0500
PSTH-97162GT-PT EVAL MODERATE COMPLEXITY 4 4.000000 204.2000 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 3 3.000000 153.1500 51.0500
PSTH-97163GT-PT EVAL HIGH COMPLEXITY 1 1.000000 51.0500 51.0500
Subtotal (Total Children Is Unduplicated) 291 723.000000 47180.9100 65.2571
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 668 4770.000000 238500.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 121 632.000000 31600.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 10 54.000000 3857.7600 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 29 159.500000 9123.4000 57.2000
OCCT-97530HMGT-OT SESSION BY OT ASST 2 13.000000 743.6000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 9 46.500000 3321.9600 71.4400
PHY-97110HM-PT SESSION BY PT ASST 23 129.000000 7373.6400 57.1600
PHY-97110HMGT-PT SESSION BY LICENSED PT ASST 2 3.000000 171.4800 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 5 15.000000 1071.6000 71.4400
Subtotal (Total Children Is Unduplicated) 793 5822.000000 295763.4400 50.8010
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Total 12515.750000 563762.3500 45.0442
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Number of Children (Unduplicated) With at Least One Service 1365
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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 97 160.250000 6314.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 1598 5821.000000 295593.1900 0.0000
T 0 0.000000 0.0000 0.0000
445 604.750000 29601.9100 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 5789 12515.750000 563762.3500 66848.5000