CMS/EIP Fiscal Report Center: 01
Services beginning 07/01/2019 ending 09/30/2019 Date of Report:11/04/2019 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 1904 5507.000000 203629.5000 36.9765
Subtotal (Total Children Is Unduplicated) 1904 5507.000000 203629.5000 36.9765
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 11 18.500000 1387.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 3 6.000000 450.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 22 55.500000 4162.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 9 15.000000 832.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 122 166.000000 12450.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 12 17.500000 1312.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 22 34.000000 2550.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 292 457.500000 25391.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 233 409.500000 30712.5000 75.0000
OCTH-97167-OT EVAL HIGH COMPLEXITY 2 2.000000 102.1000 51.0500
PSTH-97162-PT EVAL MODERATE COMPLEXITY 3 3.000000 153.1500 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 3 3.000000 153.1500 51.0500
Subtotal (Total Children Is Unduplicated) 406 1187.500000 79657.1500 67.0797
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 153 654.500000 32725.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 26 140.250000 10019.4600 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 1 6.000000 343.2000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 43 180.250000 12874.0600 71.4234
PHY-97110HM-PT SESSION BY PT ASST 5 12.000000 685.9200 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 37 132.500000 8877.4100 66.9993
SPL-92508-GROUP SPL SESSION PER CHILD 4 17.000000 235.9600 13.8800
Subtotal (Total Children Is Unduplicated) 241 1142.500000 65761.0100 57.5589
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Total 7837.000000 349047.6600 44.5384
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Number of Children (Unduplicated) With at Least One Service 1929
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Center 01
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 211 227.500000 13331.6000 0.0000
P 4 3.000000 111.0000 111.0000
D 125 127.500000 6239.0600 0.0000
S 3681 2823.000000 128892.6800 0.0000
H 6068 4236.250000 173847.1300 173847.1300
T 1 0.500000 18.5000 0.0000
29 14.250000 561.6900 0.0000
Other 277 405.000000 26046.0000 0.0000
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Total 10396 7837.000000 349047.6600 173958.1300