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:OTHER
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 3 7.000000 259.0000 37.0000
Subtotal (Total Children Is Unduplicated) 3 7.000000 259.0000 37.0000
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Screening, Eval, and Assessment,Class #02
OCTH-97167GT-OT EVAL HIGH COMPLEXITY 1 1.000000 51.0500 51.0500
SPCH-92523GT-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 1 1.000000 51.0500 51.0500
Subtotal (Total Children Is Unduplicated) 2 2.000000 102.1000 51.0500
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EI Services,Class #03
CONOF-CONOF-CONSULT, OT, FACE TO FACE 1 1.000000 50.0000 50.0000
CONSF-CONSFGT-CONSULT,SLP,FACE TO FACE 1 1.000000 50.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 4 9.000000 90.0000 10.0000
PHY-97110HM-PT SESSION BY PT ASST 1 5.000000 285.8000 57.1600
PHY-97110HMGT-PT SESSION BY LICENSED PT ASST 1 1.000000 57.1600 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 1 1.000000 71.4400 71.4400
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 1 1.500000 107.1600 71.4400
Subtotal (Total Children Is Unduplicated) 7 19.500000 711.5600 36.4903
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Total 28.500000 1072.6600 37.6372
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Number of Children (Unduplicated) With at Least One Service 12
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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 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
7 7.000000 259.0000 0.0000
Other 12 21.500000 813.6600 813.6600
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Total 19 28.500000 1072.6600 813.6600