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:TPIN
Eligibility Filter:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
CASE-CASE-NON-TCM CASE MANAGEMENT 3 0.750000 27.7500 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 18 22.000000 804.7500 36.5795
Subtotal (Total Children Is Unduplicated) 20 22.750000 832.5000 36.5934
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
EXIT-EXIT-EXIT ASSESSMENT 1 1.000000 50.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 2.000000 150.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 2 4.000000 222.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 57 134.500000 9018.1700 67.0496
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 35 90.000000 5990.1300 66.5570
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 11 25.000000 1711.9900 68.4796
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 73 142.500000 7908.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 3 6.000000 450.0000 75.0000
OCTH-97165-OT EVAL LOW COMPLEXITY 1 1.000000 51.0500 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 5 5.000000 255.2500 51.0500
PSTH-97162-PT EVAL MODERATE COMPLEXITY 1 1.000000 51.0500 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 2 3.000000 102.1000 34.0333
SCREEN-T1023-SCREENING 12 12.000000 600.0000 50.0000
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 6 6.000000 306.3000 51.0500
Subtotal (Total Children Is Unduplicated) 104 433.000000 26866.7900 62.0480
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 114 675.250000 33062.5000 48.9633
OCCT-97530-OT SESSION BY LICENSED OT 25 109.500000 7471.2200 68.2303
OCCT-97530HM-OT SESSION BY OT ASST 13 78.500000 4375.8000 55.7427
PHY-97110-PT SESSION BY LICENSED PT 26 135.250000 8934.2800 66.0575
PHY-97110HM-PT SESSION BY PT ASST 1 2.000000 114.3200 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 96 576.500000 37615.3800 65.2478
Subtotal (Total Children Is Unduplicated) 229 1577.000000 91573.5000 58.0682
-----------------------------------------------------------------------------------------------------------------------
Total 2032.750000 119272.7900 58.6756
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 283
-----------------------------------------------------------------------------------------------------------------------
Center 52
Flag Claims Units Chgs Paid
---------------------------------------------------------
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 81 110.250000 7525.1800 4126.5600
D 1 2.000000 150.0000 0.0000
S 16 13.250000 481.0000 0.0000
H 79 108.250000 7399.9800 0.0000
T 682 1003.250000 57577.3400 51639.6900
493 795.750000 46139.2900 145.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1352 2032.750000 119272.7900 55911.2500