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
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 473 1283.250000 47165.7500 36.7549
Subtotal (Total Children Is Unduplicated) 473 1283.250000 47165.7500 36.7549
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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
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 6 12.000000 666.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 90 173.500000 13012.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 48 95.000000 6985.0000 73.5263
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 25 45.000000 3375.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 120 233.500000 12959.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 8 16.000000 1200.0000 75.0000
OCTH-97166-OT EVAL MODERATE COMPLEXITY 2 2.000000 102.1000 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 2 2.000000 102.1000 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 1 1.000000 51.0500 51.0500
SCREEN-T1023-SCREENING 14 14.000000 700.0000 50.0000
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 8 8.000000 408.4000 51.0500
Subtotal (Total Children Is Unduplicated) 153 614.000000 40461.4000 65.8980
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 229 1270.000000 63500.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 53 239.500000 17109.8800 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 31 154.000000 8808.8000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 42 212.750000 15158.8600 71.2520
PHY-97110HM-PT SESSION BY PT ASST 4 17.000000 971.7200 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 106 522.250000 37309.5400 71.4400
SPL-92508-GROUP SPL SESSION PER CHILD 2 3.750000 52.0500 13.8800
Subtotal (Total Children Is Unduplicated) 381 2419.250000 142910.8500 59.0724
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Total 4316.500000 230538.0000 53.4085
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Number of Children (Unduplicated) With at Least One Service 554
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Center 52
Flag Claims Units Chgs Paid
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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 5 4.500000 255.5000 75.0000
H 38 35.250000 2497.8700 0.0000
T 0 0.000000 0.0000 0.0000
986 2057.500000 124537.6700 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 3187 4316.500000 230538.0000 88382.0200