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: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-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 3 6.000000 450.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 3 8.000000 430.0000 53.7500
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 35 69.000000 3829.5000 55.5000
OCTH-97166-OT EVAL MODERATE COMPLEXITY 1 1.000000 51.0500 51.0500
SCREEN-T1023-SCREENING 4 4.000000 200.0000 50.0000
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 5 6.000000 306.3000 51.0500
Subtotal (Total Children Is Unduplicated) 72 221.500000 14010.3500 63.2521
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 33 132.750000 6617.5000 49.8493
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 7 17.500000 805.0000 46.0000
OCCT-97530-OT SESSION BY LICENSED OT 2 4.000000 285.7600 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 35 207.750000 13676.8200 65.8331
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 9 28.750000 1951.0200 67.8616
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 2 4.000000 285.7600 71.4400
Subtotal (Total Children Is Unduplicated) 77 394.750000 23621.8600 59.8401
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Total 617.000000 37659.9600 61.0372
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Number of Children (Unduplicated) With at Least One Service 133
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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 245 270.500000 16981.7300 11269.9400
60 73.500000 5004.7100 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 527 617.000000 37659.9600 14201.1200