CMS/EIP Fiscal Report Center: 57
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:Part C (excluding not eligible)
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 2 2.500000 187.5000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 2 3.000000 225.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 1.500000 112.5000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 1 1.500000 112.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 1.500000 112.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 2 2.000000 111.0000 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 3 4.500000 249.7500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 24 33.000000 2475.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 32 41.000000 3075.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 1 1.500000 112.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 15 17.500000 1312.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 3 4.500000 337.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 15 21.500000 1612.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 25 35.000000 1942.5000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 52 74.000000 4107.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 2 3.000000 225.0000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 12 15.000000 1125.0000 75.0000
OCTH-97167-OT EVAL HIGH COMPLEXITY 5 5.000000 255.2500 51.0500
OCTH-97167GT-OT EVAL HIGH COMPLEXITY 6 6.000000 306.3000 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 2 2.000000 102.1000 51.0500
PSTH-97163GT-PT EVAL HIGH COMPLEXITY 2 2.000000 102.1000 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 6 6.000000 306.3000 51.0500
SPCH-92523GT-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 2 2.000000 102.1000 51.0500
Subtotal (Total Children Is Unduplicated) 109 285.500000 18609.4000 65.1818
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EI Services,Class #03
CONPF-CONPFGT-CONSULT,PT,FACE TO FACE 1 1.000000 50.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 207 1299.000000 64950.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 73 327.750000 16387.5000 50.0000
OCCT-97530GT-OT SESSION BY LICENSED OT 5 12.000000 857.2800 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 2 2.000000 114.4000 57.2000
OCCT-97530HMGT-OT SESSION BY OT ASST 3 13.000000 743.6000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 2 5.000000 357.2000 71.4400
PHY-97110GT-PT SESSION BY LICENSED PT 2 8.500000 607.2400 71.4400
PHY-97110HM-PT SESSION BY PT ASST 3 17.000000 971.7200 57.1600
PHY-97110HMGT-PT SESSION BY LICENSED PT ASST 2 6.500000 371.5400 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 12 67.500000 4822.2000 71.4400
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 14 55.750000 3982.7800 71.4400
Subtotal (Total Children Is Unduplicated) 267 1815.000000 94215.4600 51.9093
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Total 2100.500000 112824.8600 53.7133
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Number of Children (Unduplicated) With at Least One Service 330
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Center 57
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 0 0.000000 0.0000 0.0000
S 1 1.000000 50.0000 50.0000
H 0 0.000000 0.0000 0.0000
T 549 1680.250000 85776.1200 85776.1200
267 419.250000 26998.7400 8893.4500
Other 0 0.000000 0.0000 0.0000
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Total 817 2100.500000 112824.8600 94719.5700