CMS/EIP Fiscal Report Center: 53
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 0.250000 9.2500 37.0000
Subtotal (Total Children Is Unduplicated) 1 0.250000 9.2500 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 1 2.000000 150.0000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 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 17 33.500000 2512.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 2 3.000000 225.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 14 27.000000 2025.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 7 13.000000 975.0000 75.0000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 26 49.000000 2719.5000 55.5000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 12 21.000000 1575.0000 75.0000
Subtotal (Total Children Is Unduplicated) 48 156.500000 10665.0000 68.1470
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 4 4.000000 200.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 34 158.000000 7900.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 1 1.000000 71.4400 71.4400
OCCT-97530GT-OT SESSION BY LICENSED OT 21 96.250000 6876.1000 71.4400
PHY-97110-PT SESSION BY LICENSED PT 1 2.000000 142.8800 71.4400
PHY-97110GT-PT SESSION BY LICENSED PT 13 96.750000 6911.8200 71.4400
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 33 131.750000 9390.7800 71.2773
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 1 2.000000 142.8800 71.4400
Subtotal (Total Children Is Unduplicated) 101 491.750000 31635.9000 64.3333
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Total 648.500000 42310.1500 65.2431
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Number of Children (Unduplicated) With at Least One Service 132
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Center 53
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 0 0.000000 0.0000 0.0000
D 3 3.000000 171.4400 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 2 2.000000 105.5000 0.0000
550 617.500000 40411.6100 0.0000
Other 26 26.000000 1621.6000 0.0000
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Total 581 648.500000 42310.1500 0.0000