CMS/EIP Fiscal Report Center: 09
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 1295 4445.000000 164465.0000 37.0000
Subtotal (Total Children Is Unduplicated) 1295 4445.000000 164465.0000 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 7 11.500000 862.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 6 12.000000 900.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 7 13.000000 975.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 6 10.000000 750.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 11 20.500000 1137.7500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 120 186.500000 13987.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 58 100.000000 7500.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 112 188.500000 14090.0000 74.7480
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 186 321.000000 17787.7500 55.4136
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 89 137.500000 10312.5000 75.0000
Subtotal (Total Children Is Unduplicated) 302 1000.500000 68303.0000 68.2689
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 832 5650.250000 282512.5000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 52 296.000000 21132.0000 71.3919
PHY-97110-PT SESSION BY LICENSED PT 98 731.000000 52222.6400 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 161 1249.500000 89264.2800 71.4400
Subtotal (Total Children Is Unduplicated) 993 7926.750000 445131.4200 56.1556
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Total 13372.250000 677899.4200 50.6945
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Number of Children (Unduplicated) With at Least One Service 1478
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Center 09
Flag Claims Units Chgs Paid
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R 2 1.500000 55.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 345 377.000000 15821.2500 0.0000
P 4416 4841.250000 196861.5000 200487.5000
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 5 9.000000 528.7500 637.5000
2491 7775.000000 437843.1700 0.0000
Other 217 368.500000 26789.2500 0.0000
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Total 7476 13372.250000 677899.4200 201125.0000