CMS/EIP Fiscal Report Center: 10
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 1935 6390.500000 236189.5000 36.9595
Subtotal (Total Children Is Unduplicated) 1935 6390.500000 236189.5000 36.9595
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 2 4.000000 300.0000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 9 15.500000 1162.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 3 5.500000 412.5000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 2 4.000000 300.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 2 4.000000 222.0000 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 7 13.000000 721.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 40 78.000000 5850.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 214 395.500000 29662.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 13 25.000000 1875.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 78 143.000000 10725.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 12 23.000000 1725.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 53 94.000000 7050.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 47 90.000000 4995.0000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 168 305.000000 16927.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 10 18.500000 1348.5000 72.8919
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 59 114.000000 8550.0000 75.0000
OCTH-97166-OT EVAL MODERATE COMPLEXITY 4 4.000000 204.2000 51.0500
OCTH-97166GT-OT EVAL MODERATE COMPLEXITY 1 1.000000 51.0500 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 6 6.000000 306.3000 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 6 6.000000 306.3000 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 3 3.000000 153.1500 51.0500
SPCH-92523GT-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 4 4.000000 204.2000 51.0500
SPCH-92524-BEHAV & QUAL ANALYSIS OF VOICE AND RES 12 12.000000 612.6000 51.0500
SPCH-92524GT-BEHAV & QUAL ANALYSIS OF VOICE AND RES 3 3.000000 153.1500 51.0500
Subtotal (Total Children Is Unduplicated) 374 1373.000000 93967.9500 68.4399
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 4 7.000000 4319.6600 617.0943
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 408 3534.500000 176676.0000 49.9861
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 510 3428.250000 171412.5000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 132 548.000000 39149.1200 71.4400
OCCT-97530GT-OT SESSION BY LICENSED OT 41 211.500000 15109.5600 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 23 103.000000 5891.6000 57.2000
OCCT-97530HMGT-OT SESSION BY OT ASST 2 4.000000 228.8000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 211 882.250000 63027.9400 71.4400
PHY-97110GT-PT SESSION BY LICENSED PT 56 184.500000 13180.6800 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 186 826.750000 58973.7200 71.3320
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 87 440.750000 31487.1800 71.4400
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 1 3.500000 250.0400 71.4400
SPL-92508-GROUP SPL SESSION PER CHILD 1 2.000000 27.7600 13.8800
Subtotal (Total Children Is Unduplicated) 1110 10176.00000 579734.5600 56.9708
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Total 17939.500000 909892.0100 50.7200
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Number of Children (Unduplicated) With at Least One Service 2139
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Center 10
Flag Claims Units Chgs Paid
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R 305 227.750000 8898.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 1525 1207.750000 47606.5000 0.0000
P 7234 5978.250000 251119.5100 252866.1000
D 89 111.500000 6975.2500 0.0000
S 114 209.500000 14298.7500 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
3368 10204.750000 580993.2500 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 12635 17939.500000 909892.0100 252866.1000