CMS/EIP Fiscal Report Center: 52
Services beginning 07/01/2019 ending 09/30/2019 Date of Report:11/04/2019 Page: 1
List order: No List
Payclass Filters:MED
Bill Flag Filter:RBPU
Eligibility Filter:All
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 473 1280.000000 47045.5000 36.7543
Subtotal (Total Children Is Unduplicated) 473 1280.000000 47045.5000 36.7543
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 5 10.000000 750.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 84 162.000000 12150.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 45 89.000000 6535.0000 73.4270
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 11 19.000000 1425.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 49 96.000000 5328.0000 55.5000
SCREEN-T1023-SCREENING 10 10.000000 500.0000 50.0000
Subtotal (Total Children Is Unduplicated) 115 388.000000 26838.0000 69.1701
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 90 467.250000 23362.5000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 3 22.000000 1571.6800 71.4400
PHY-97110-PT SESSION BY LICENSED PT 1 3.000000 214.3200 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 18 59.000000 4214.9600 71.4400
Subtotal (Total Children Is Unduplicated) 109 551.250000 29363.4600 53.2670
-----------------------------------------------------------------------------------------------------------------------
Total 2219.250000 103246.9600 46.5234
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 498
-----------------------------------------------------------------------------------------------------------------------
Center 52
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 15 12.750000 743.3900 0.0000
U 0 0.000000 0.0000 0.0000
B 289 301.750000 14234.5800 0.0000
P 1854 1904.750000 88268.9900 88307.0200
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
0 0.000000 0.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 2158 2219.250000 103246.9600 88307.0200