CMS/EIP Fiscal Report Center: 09
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:Part C (excluding not eligible)
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 989 3373.000000 124680.7500 36.9643
Subtotal (Total Children Is Unduplicated) 989 3373.000000 124680.7500 36.9643
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 5 10.000000 750.0000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 7 13.000000 975.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 4 8.000000 561.0000 70.1250
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 1 1.500000 112.5000 75.0000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 12 23.500000 1304.2500 55.5000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 78 153.500000 11512.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 42 83.500000 6262.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 51 99.000000 7425.0000 75.0000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 138 270.000000 14985.0000 55.5000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 18 36.000000 2700.0000 75.0000
PSTF-97164GT-PT RE-EVAL EST PLAN CARE 1 1.000000 51.0500 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 1 1.000000 51.0500 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 1 1.000000 51.0500 51.0500
Subtotal (Total Children Is Unduplicated) 182 703.000000 46890.9000 66.7011
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 510 3791.000000 189550.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 126 576.000000 28800.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 53 262.000000 18717.2800 71.4400
OCCT-97530GT-OT SESSION BY LICENSED OT 4 12.000000 857.2800 71.4400
PHY-97110-PT SESSION BY LICENSED PT 57 347.500000 24825.4000 71.4400
PHY-97110GT-PT SESSION BY LICENSED PT 15 46.750000 3339.8200 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 99 762.250000 54455.1400 71.4400
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 24 134.000000 9572.9600 71.4400
SPL-92508-GROUP SPL SESSION PER CHILD 1 4.000000 55.5200 13.8800
Subtotal (Total Children Is Unduplicated) 708 5935.500000 330173.4000 55.6269
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Total 10011.500000 501745.0500 50.1169
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Number of Children (Unduplicated) With at Least One Service 1105
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Center 09
Flag Claims Units Chgs Paid
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R 12 10.500000 370.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 769 824.000000 31310.2500 0.0000
P 2716 2951.500000 118463.7500 118463.7500
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 6 18.500000 758.5000 536.5000
1779 5931.000000 331839.0500 0.0000
Other 140 276.000000 19003.5000 0.0000
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Total 5422 10011.500000 501745.0500 119000.2500