CMS/EIP Fiscal Report Center: 06
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 1280 4119.000000 152403.0000 37.0000
Subtotal (Total Children Is Unduplicated) 1280 4119.000000 152403.0000 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 1 1.500000 112.5000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 1 1.500000 83.2500 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 2 3.000000 166.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 42 69.500000 5212.5000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 135 218.500000 16387.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 12 18.000000 1350.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 40 61.500000 4612.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 9 15.500000 1162.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 54 92.500000 6937.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 43 71.000000 3940.5000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 113 188.000000 10434.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 1.500000 112.5000 75.0000
Subtotal (Total Children Is Unduplicated) 227 742.000000 50511.7500 68.0751
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 492 3043.000000 152150.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 181 804.000000 40155.0000 49.9440
OCCT-97530-OT SESSION BY LICENSED OT 21 90.000000 6429.6000 71.4400
OCCT-97530GT-OT SESSION BY LICENSED OT 3 8.000000 392.9200 49.1150
OCCT-97530HM-OT SESSION BY OT ASST 6 18.000000 1029.6000 57.2000
OCCT-97530HMGT-OT SESSION BY OT ASST 2 8.000000 457.6000 57.2000
OCCT-97530TLGT-OT SESSION BY LICENSED OT 1 0.500000 35.7200 71.4400
PHY-97110-PT SESSION BY LICENSED PT 32 94.000000 6715.3600 71.4400
PHY-97110GT-PT SESSION BY LICENSED PT 10 26.000000 1814.5600 69.7908
PHY-97110HM-PT SESSION BY PT ASST 9 27.000000 1543.3200 57.1600
PHY-97110HMGT-PT SESSION BY LICENSED PT ASST 2 1.500000 85.7400 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 34 124.500000 8842.8400 71.0268
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 12 33.750000 2411.1000 71.4400
Subtotal (Total Children Is Unduplicated) 652 4278.250000 222063.3600 51.9052
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Total 9139.250000 424978.1100 46.5003
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Number of Children (Unduplicated) With at Least One Service 1372
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Center 06
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 0 0.000000 0.0000 0.0000
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
11384 9139.250000 424978.1100 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 11384 9139.250000 424978.1100 0.0000