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:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 1031 3500.750000 129407.5000 36.9657
Subtotal (Total Children Is Unduplicated) 1031 3500.750000 129407.5000 36.9657
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 6 12.000000 900.0000 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 5 10.000000 711.0000 71.1000
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 99 191.000000 14325.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 54 107.500000 8062.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 73 142.000000 10650.0000 75.0000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 175 340.000000 18870.0000 55.5000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 24 47.500000 3562.5000 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) 232 893.000000 59775.9000 66.9383
-----------------------------------------------------------------------------------------------------------------------
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
-----------------------------------------------------------------------------------------------------------------------
Total 10329.250000 519356.8000 50.2802
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 1158
-----------------------------------------------------------------------------------------------------------------------
Center 09
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 12 10.500000 370.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 800 878.250000 33354.5000 0.0000
P 2799 3096.000000 125437.7500 125437.7500
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 8 22.500000 980.5000 592.0000
1791 5955.000000 333639.0500 0.0000
Other 188 367.000000 25575.0000 0.0000
---------------------------------------------------------
Total 5598 10329.250000 519356.8000 126029.7500