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
Payclass Filters:MED
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 885 2646.500000 97828.0000 36.9650
Subtotal (Total Children Is Unduplicated) 885 2646.500000 97828.0000 36.9650
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 1 1.500000 112.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 2 3.000000 225.0000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 1 1.500000 112.5000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 3 5.500000 412.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 4 7.500000 416.2500 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 6 10.000000 499.5000 49.9500
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 2 4.000000 300.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 68 131.500000 9862.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 9 17.000000 1275.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 64 118.000000 8850.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 43 78.500000 5887.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 2 3.500000 194.2500 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 130 249.000100 13819.5055 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 2.000000 150.0000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 66 120.500000 9037.5000 75.0000
Subtotal (Total Children Is Unduplicated) 214 755.000100 51304.5055 67.9530
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EI Services,Class #03
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 3 1.500000 37.5000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 27 71.000000 3550.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 334 1560.750000 78037.5000 50.0000
OCCT-97530GT-OT SESSION BY LICENSED OT 17 29.000000 2071.7600 71.4400
OCCT-97530TL-OT SESSION BY LICENSED OT 1 1.000000 71.4400 71.4400
OCCT-97530TLGT-OT SESSION BY LICENSED OT 36 172.500000 12323.4000 71.4400
PHY-97110GT-PT SESSION BY LICENSED PT 12 28.000000 2000.3200 71.4400
PHY-97110TLGT-PT SESSION BY LICENSED PT 21 115.250000 8233.4600 71.4400
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 2 6.000000 428.6400 71.4400
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 38 167.250000 11948.3400 71.4400
SPL-92508TLGT-SPL THERAPY SESSION BY LICENSED SLP 1 1.000000 13.8800 13.8800
Subtotal (Total Children Is Unduplicated) 457 2153.250000 118716.2400 55.1335
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Total 5554.750100 267848.7455 48.2198
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Number of Children (Unduplicated) With at Least One Service 985
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Center 53
Flag Claims Units Chgs Paid
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R 11 11.750000 469.1900 0.0000
U 0 0.000000 0.0000 0.0000
B 3414 3075.750000 145865.0400 0.0000
P 1376 1337.250100 62490.3955 62180.6400
D 69 71.500000 3999.3500 0.0000
S 7 7.000000 350.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 2 4.000000 222.0000 0.0000
995 1031.500000 53360.1100 0.0000
Other 20 16.000000 1092.6600 37.0000
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Total 5894 5554.750100 267848.7455 62217.6400