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
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 430 1390.750000 51285.0000 36.8758
Subtotal (Total Children Is Unduplicated) 430 1390.750000 51285.0000 36.8758
-----------------------------------------------------------------------------------------------------------------------
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 3 6.000000 450.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 3 5.000000 277.5000 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 3 6.000000 333.0000 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 78 153.000000 11475.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 50 99.000000 7425.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 18 36.000000 2700.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 18 36.000000 1998.0000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 64 128.000000 7104.0000 55.5000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 3 6.000000 450.0000 75.0000
OCTH-97166TL-OT EVAL MODERATE COMPLEXITY 7 7.000000 357.3500 51.0500
OCTH-97166TLGT-OT EVAL MODERATE COMPLEXITY 1 1.000000 51.0500 51.0500
PSTH-97162TL-PT EVAL MODERATE COMPLEXITY 1 1.000000 51.0500 51.0500
SCREEN-T1023-SCREENING 21 21.000000 1050.0000 50.0000
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 2 2.000000 102.1000 51.0500
SPCH-92523TL-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 12 12.000000 612.6000 51.0500
SPCH-92523TLGT-EVAL OF SPCH SOUND PROD; EVAL LANG COM 1 1.000000 51.0500 51.0500
Subtotal (Total Children Is Unduplicated) 134 534.000000 35537.7000 66.5500
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 178 982.000000 49060.0000 49.9593
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 35 93.250000 4632.5000 49.6783
OCCT-97530GT-OT SESSION BY LICENSED OT 1 1.000000 71.4400 71.4400
OCCT-97530TL-OT SESSION BY LICENSED OT 37 197.750000 14127.2600 71.4400
OCCT-97530TLGT-OT SESSION BY LICENSED OT 15 28.500000 2036.0400 71.4400
OCCT-97530TLGTHM-OT SESSION BY OT ASST 3 4.500000 257.4000 57.2000
OCCT-97530TLHM-OT SESSION BY OT ASST 7 14.500000 829.4000 57.2000
PHY-97110TL-PT SESSION BY LICENSED PT 30 168.500000 12037.6400 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 4 17.000000 1214.4800 71.4400
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 1 1.000000 71.4400 71.4400
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 84 391.250000 27950.9000 71.4400
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 5 26.500000 1893.1600 71.4400
Subtotal (Total Children Is Unduplicated) 304 1925.750000 114181.6600 59.2920
-----------------------------------------------------------------------------------------------------------------------
Total 3850.500000 201004.3600 52.2021
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 470
-----------------------------------------------------------------------------------------------------------------------
Center 52
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 6 6.250000 307.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 429 449.750000 23363.8700 0.0000
P 1486 1532.000000 67422.1000 67303.4000
D 2 2.000000 70.0000 0.0000
S 271 281.000000 12103.7100 155.0500
H 9 9.000000 581.5200 0.0000
T 0 0.000000 0.0000 0.0000
728 1570.500000 97155.9100 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 2931 3850.500000 201004.3600 67458.4500