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:Program Patients
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 4 7.000000 525.0000 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 5 9.500000 527.2500 55.5000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 68 141.000000 9820.0000 69.6454
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 48 100.000000 7050.0000 70.5000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 15 35.500000 2332.5000 65.7042
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 4 8.000000 444.0000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 66 130.000000 7215.0000 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) 114 477.000000 30555.1400 64.0569
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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 2327.750000 143638.7600 61.7071
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Number of Children (Unduplicated) With at Least One Service 310
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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 53 71.750000 3839.2400 3289.6200
D 95 122.500000 6602.3200 0.0000
S 2 0.750000 27.7500 0.0000
H 95 123.000000 8064.7100 40.0000
T 705 1241.750000 77810.8300 71919.0400
413 768.000000 47293.9100 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 1363 2327.750000 143638.7600 75248.6600