CMS/EIP Fiscal Report Center: 10
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 2297 6793.500000 251248.5000 36.9837
Subtotal (Total Children Is Unduplicated) 2297 6793.500000 251248.5000 36.9837
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 12 21.500000 1612.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 1.000000 75.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 2.000000 150.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 11 21.500000 1193.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 258 467.000000 35025.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 85 146.000000 10950.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 62 100.000000 7500.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 242 447.000000 24808.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 43 85.000000 6375.0000 75.0000
OCTH-97166-OT EVAL MODERATE COMPLEXITY 1 1.000000 51.0500 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 4 4.000000 204.2000 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 3 3.000000 153.1500 51.0500
SPCH-92522-EVAL OF SPCH SOUND PROD 1 1.000000 51.0500 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 5 5.000000 255.2500 51.0500
SPCH-92524-BEHAV & QUAL ANALYSIS OF VOICE AND RES 6 6.000000 306.3000 51.0500
Subtotal (Total Children Is Unduplicated) 358 1313.000000 88860.2500 67.6773
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 2 25.000000 2641.9700 105.6788
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1238 12111.50000 605525.0000 49.9959
OCCT-97530-OT SESSION BY LICENSED OT 114 524.750000 37434.1400 71.3371
OCCT-97530HM-OT SESSION BY OT ASST 13 25.750000 1472.9000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 155 627.500000 44811.7900 71.4132
PHY-97110HM-PT SESSION BY PT ASST 2 2.000000 114.3200 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 140 674.000000 47833.0600 70.9689
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 3 6.500000 371.8000 57.2000
SPL-92508-GROUP SPL SESSION PER CHILD 3 4.500000 62.4600 13.8800
Subtotal (Total Children Is Unduplicated) 1413 14001.50000 740267.4400 52.8706
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Total 22108.000000 1080376.1900 48.8681
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Number of Children (Unduplicated) With at Least One Service 2561
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Center 10
Flag Claims Units Chgs Paid
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R 114 81.750000 3024.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 2859 2195.750000 86692.5000 0.0000
P 6748 5808.250000 249372.9700 249187.5000
D 2 2.000000 100.0000 0.0000
S 32 81.000000 4575.2800 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
4364 13939.250000 736610.6900 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 14119 22108.000000 1080376.1900 249187.5000