CMS/EIP Fiscal Report Center: 03
Services beginning 07/01/2019 ending 09/30/2019 Date of Report:11/04/2019 Page: 1
List order: No List
Payclass Filters:TPIN
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 7 14.000000 518.0000 37.0000
Subtotal (Total Children Is Unduplicated) 7 14.000000 518.0000 37.0000
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Screening, Eval, and Assessment,Class #02
OCTF-97168-OT RE-EVAL EST PLAN CARE 4 4.000000 165.8600 41.4650
OCTH-97165-OT EVAL LOW COMPLEXITY 1 1.000000 10.2100 10.2100
PSTF-97164-PT RE-EVAL EST PLAN CARE 3 3.000000 75.9700 25.3233
PSTH-97161-PT EVAL LOW COMPLEXITY 1 1.000000 51.0500 51.0500
PSTH-97162-PT EVAL MODERATE COMPLEXITY 2 2.000000 61.2700 30.6350
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 3 3.000000 153.1500 51.0500
Subtotal (Total Children Is Unduplicated) 14 14.000000 517.5100 36.9650
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EI Services,Class #03
OCCT-97530-OT SESSION BY LICENSED OT 10 75.750000 3708.0200 48.9508
PHY-97110-PT SESSION BY LICENSED PT 13 57.500000 3598.7100 62.5863
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 14 60.250000 3066.1500 50.8905
Subtotal (Total Children Is Unduplicated) 35 193.500000 10372.8800 53.6066
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Total 221.500000 11408.3900 51.5051
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Number of Children (Unduplicated) With at Least One Service 43
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Center 03
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 77 76.250000 3961.6500 3961.6500
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 2 2.000000 114.8200 114.8200
T 17 17.000000 952.5900 952.5900
142 126.250000 6379.3300 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 238 221.500000 11408.3900 5029.0600