CMS/EIP Fiscal Report Center: 52
Services beginning 10/01/2020 ending 12/31/2020 Date of Report:01/23/2021 Page: 1
List order: No List
Payclass Filters:MED
Bill Flag Filter:RBPU
Eligibility Filter:All
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 422 1309.250000 48433.0000 36.9929
Subtotal (Total Children Is Unduplicated) 422 1309.250000 48433.0000 36.9929
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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-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 2 3.000000 166.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 1 2.000000 150.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 96 185.500000 13912.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 2 4.000000 300.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 15 29.000000 2175.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 19 38.000000 2109.0000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 43 84.000000 4662.0000 55.5000
SCREEN-T1023-SCREENING 6 6.000000 300.0000 50.0000
SPCH-92523TL-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 4 4.000000 204.2000 51.0500
Subtotal (Total Children Is Unduplicated) 117 365.500000 24729.2000 67.6586
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 68 358.500000 17925.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 4 15.000000 750.0000 50.0000
OCCT-97530TL-OT SESSION BY LICENSED OT 1 3.000000 214.3200 71.4400
OCCT-97530TLGT-OT SESSION BY LICENSED OT 1 1.000000 71.4400 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 3 9.000000 642.9600 71.4400
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 19 86.500000 6179.5600 71.4400
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 1 2.250000 160.7400 71.4400
Subtotal (Total Children Is Unduplicated) 88 475.250000 25944.0200 54.5903
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Total 2150.000000 99106.2200 46.0959
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Number of Children (Unduplicated) With at Least One Service 433
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Center 52
Flag Claims Units Chgs Paid
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R 6 6.250000 307.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 449 478.250000 24824.6200 0.0000
P 1567 1665.500000 73974.3500 73855.6800
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
0 0.000000 0.0000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 2022 2150.000000 99106.2200 73855.6800