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:TPIN
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 1 0.750000 27.7500 37.0000
Subtotal (Total Children Is Unduplicated) 1 0.750000 27.7500 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 3 6.000000 450.0000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 2 4.000000 300.0000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 3 6.000000 333.0000 55.5000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 53 109.500000 7627.5000 69.6575
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 42 88.000000 6150.0000 69.8864
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 7 16.000000 1030.0000 64.3750
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 3 6.000000 333.0000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 51 101.000000 5605.5000 55.5000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 4 8.000000 600.0000 75.0000
OCTH-97166-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 11 11.000000 550.0000 50.0000
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 14 16.000000 786.1400 49.1338
SPCH-92523GT-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 3 3.000000 153.1500 51.0500
Subtotal (Total Children Is Unduplicated) 94 378.500000 24170.3900 63.8584
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 86 406.000000 20180.0000 49.7044
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 31 90.250000 4442.5000 49.2244
OCCT-97530-OT SESSION BY LICENSED OT 29 102.500000 6911.8200 67.4324
OCCT-97530GT-OT SESSION BY LICENSED OT 9 19.750000 1268.0600 64.2056
OCCT-97530HM-OT SESSION BY OT ASST 10 29.500000 1401.4000 47.5051
OCCT-97530HMGT-OT SESSION BY OT ASST 2 2.500000 143.0000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 34 197.000000 12537.7200 63.6432
PHY-97110GT-PT SESSION BY LICENSED PT 2 7.500000 321.4800 42.8640
PHY-97110TL-PT SESSION BY LICENSED PT 1 3.750000 267.9000 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 138 922.250000 60862.6700 65.9937
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 21 63.000000 4290.6800 68.1060
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 3 6.000000 428.6400 71.4400
Subtotal (Total Children Is Unduplicated) 261 1850.000000 113055.8700 61.1113
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Total 2229.250000 137254.0100 61.5696
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Number of Children (Unduplicated) With at Least One Service 290
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Center 52
Flag Claims Units Chgs Paid
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R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 0 0.000000 0.0000 0.0000
P 49 63.750000 3383.2400 2891.1800
D 88 109.500000 5880.8200 0.0000
S 2 0.750000 27.7500 0.0000
H 83 99.000000 6381.7100 40.0000
T 686 1205.750000 75404.0800 69692.2900
404 750.500000 46176.4100 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 1312 2229.250000 137254.0100 72623.4700