CMS/EIP Fiscal Report Center: 06
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 1286 3099.500000 114681.5000 37.0000
Subtotal (Total Children Is Unduplicated) 1286 3099.500000 114681.5000 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 5 7.500000 562.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 1.500000 112.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 6 9.000000 499.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 218 333.000000 24975.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 62 97.000000 7275.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 88 135.000000 10125.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 214 333.000000 18481.5000 55.5000
Subtotal (Total Children Is Unduplicated) 297 916.000000 62031.0000 67.7194
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 715 5174.000000 258660.0000 49.9923
OCCT-97530-OT SESSION BY LICENSED OT 41 132.250000 9447.9400 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 10 29.500000 1687.4000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 16 60.000000 4286.4000 71.4400
PHY-97110HM-PT SESSION BY PT ASST 4 7.000000 400.1200 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 40 157.500000 11251.8000 71.4400
Subtotal (Total Children Is Unduplicated) 780 5560.250000 285733.6600 51.3886
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Total 9575.750000 462446.1600 48.2935
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Number of Children (Unduplicated) With at Least One Service 1457
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Center 06
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 3 3.000000 111.0000 111.0000
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
11040 9572.750000 462335.1600 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 11043 9575.750000 462446.1600 111.0000