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: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 990 4646.750000 171929.7500 37.0000
Subtotal (Total Children Is Unduplicated) 990 4646.750000 171929.7500 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 10 12.000000 900.0000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 3 4.000000 300.0000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 2 2.000000 150.0000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 6 8.000000 600.0000 75.0000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 9 10.000000 555.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 2 3.000000 225.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 131 163.000000 12225.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 3 3.500000 262.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 46 55.000000 4125.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 66 80.000000 6000.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 1 1.500000 83.2500 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 214 263.500000 14624.2500 55.5000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 34 44.500000 3337.5000 75.0000
OCTH-97166TLGT-OT EVAL MODERATE COMPLEXITY 1 1.000000 51.0500 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 3 3.000000 153.1500 51.0500
OCTH-97167GT-OT EVAL HIGH COMPLEXITY 2 2.000000 102.1000 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 2 2.000000 102.1000 51.0500
PSTH-97163GT-PT EVAL HIGH COMPLEXITY 1 1.000000 51.0500 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 3 3.000000 153.1500 51.0500
SPCH-92523GT-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 1 1.000000 51.0500 51.0500
Subtotal (Total Children Is Unduplicated) 273 663.000000 44051.1500 66.4422
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 503 3687.000000 184350.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 139 664.000000 33200.0000 50.0000
OCCT-97530GT-OT SESSION BY LICENSED OT 3 10.000000 714.4000 71.4400
OCCT-97530TLGT-OT SESSION BY LICENSED OT 1 4.000000 285.7600 71.4400
PHY-97110-PT SESSION BY LICENSED PT 2 12.000000 857.2800 71.4400
PHY-97110HM-PT SESSION BY PT ASST 4 15.000000 857.4000 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 2 22.000000 1571.6800 71.4400
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 1 6.500000 464.3600 71.4400
Subtotal (Total Children Is Unduplicated) 597 4420.500000 222300.8800 50.2886
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Total 9730.250000 438281.7800 45.0432
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Number of Children (Unduplicated) With at Least One Service 1065
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Center 57
Flag Claims Units Chgs Paid
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R 8 8.750000 323.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 740 903.000000 34858.5600 148.0000
P 3728 4383.750000 180274.9400 179122.1900
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
1298 4434.750000 222824.5300 222556.2800
Other 0 0.000000 0.0000 0.0000
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Total 5774 9730.250000 438281.7800 401826.4700