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
Agency Filter:EIP DEI DEIP
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
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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 3 5.000000 277.5000 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 1 2.000000 111.0000 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-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 2 4.000000 300.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 13 26.000000 1950.0000 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 41 82.000000 4551.0000 55.5000
SCREEN-T1023-SCREENING 10 10.000000 500.0000 50.0000
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 1 1.000000 51.0500 51.0500
SPCH-92523TL-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 4 4.000000 204.2000 51.0500
Subtotal (Total Children Is Unduplicated) 104 335.000000 22317.7500 66.6201
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 82 413.500000 20635.0000 49.9033
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 7 19.000000 920.0000 48.4211
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 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 19 86.500000 6179.5600 71.4400
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 3 15.250000 1089.4600 71.4400
Subtotal (Total Children Is Unduplicated) 105 556.250000 30395.7000 54.6440
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Total 2282.000000 103998.4500 45.5734
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Number of Children (Unduplicated) With at Least One Service 436
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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 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
1 2.000000 150.0000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 2204 2282.000000 103998.4500 67458.4500