CMS/EIP Fiscal Report Center: 07
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:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 9 21.750000 823.2500 37.8506
Subtotal (Total Children Is Unduplicated) 9 21.750000 823.2500 37.8506
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 2.000000 150.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 27 54.000000 4050.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 15 30.000000 2250.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 19 37.500000 2812.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 21 42.000000 3150.0000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 8 16.000000 1200.0000 75.0000
OCTH-97166-OT EVAL MODERATE COMPLEXITY 2 2.000000 102.1000 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 2 2.000000 102.1000 51.0500
PSTH-97161-PT EVAL LOW COMPLEXITY 2 2.000000 102.1000 51.0500
PSTH-97162-PT EVAL MODERATE COMPLEXITY 1 1.000000 51.0500 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 6 6.000000 306.3000 51.0500
Subtotal (Total Children Is Unduplicated) 87 198.500000 14576.1500 73.4315
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EI Services,Class #03
AUD-92593TS-AUDIOLOGY SERVICES (Biaural) 1 1.000000 50.0000 50.0000
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 3 3.000000 0.0000 0.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 12 74.000000 3700.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 5 27.000000 1350.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 14 69.000000 4911.5000 71.1812
OCCT-97530GT-OT SESSION BY LICENSED OT 4 11.000000 785.8400 71.4400
PHY-97110-PT SESSION BY LICENSED PT 11 80.000000 5715.2000 71.4400
PHY-97110GT-PT SESSION BY LICENSED PT 2 3.000000 214.3200 71.4400
SENS-V5264-EARMOLD 1 2.000000 36.0000 18.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 39 218.000000 15573.9200 71.4400
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 10 50.500000 3607.7200 71.4400
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 1 7.750000 443.3000 57.2000
Subtotal (Total Children Is Unduplicated) 79 546.250000 36387.8000 66.6138
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Total 766.500000 51787.2000 67.5632
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Number of Children (Unduplicated) With at Least One Service 164
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Center 07
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 211 580.250000 38851.4500 38851.4500
D 1 2.000000 150.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 36 72.000000 5400.0000 0.0000
T 0 0.000000 0.0000 0.0000
63 112.250000 7385.7500 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 311 766.500000 51787.2000 38851.4500