CMS/EIP Fiscal Report Center: 55
Services beginning 10/01/2020 ending 12/31/2020 Date of Report:01/23/2021 Page: 1
List order: No List
Payclass Filters:OTHER
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 3 6.000000 222.0000 37.0000
Subtotal (Total Children Is Unduplicated) 3 6.000000 222.0000 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 2 4.000000 300.0000 75.0000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 1 2.000000 111.0000 55.5000
OCTF-97168-OT RE-EVAL EST PLAN CARE 1 1.000000 51.0500 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 1 1.000000 51.0500 51.0500
Subtotal (Total Children Is Unduplicated) 4 8.000000 513.1000 64.1375
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 4 16.000000 800.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 3 4.000000 200.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 8 57.000000 4072.0800 71.4400
OCCT-97530GT-OT SESSION BY LICENSED OT 1 2.000000 142.8800 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 6 40.000000 2288.0000 57.2000
OCCT-97530HMGT-OT SESSION BY OT ASST 2 4.000000 228.8000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 4 20.750000 1482.3800 71.4400
PHY-97110HM-PT SESSION BY PT ASST 2 8.500000 485.8600 57.1600
PHY-97110HMGT-PT SESSION BY LICENSED PT ASST 1 5.000000 285.8000 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 19 120.000000 8572.8000 71.4400
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 1 1.000000 71.4400 71.4400
TRAV-TRAVS-Travel by mile 1 11.000000 4.8900 0.4445
Subtotal (Total Children Is Unduplicated) 32 289.250000 18634.9300 64.4250
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Total 303.250000 19370.0300 63.8748
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Number of Children (Unduplicated) With at Least One Service 36
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Center 55
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 230 239.250000 15290.1100 15290.1100
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
68 64.000000 4079.9200 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 298 303.250000 19370.0300 15290.1100