CMS/EIP Fiscal Report Center: 53
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 852 2271.250000 83795.7500 36.8941
Subtotal (Total Children Is Unduplicated) 852 2271.250000 83795.7500 36.8941
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 4 6.000000 450.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 1.500000 112.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 8 12.500000 937.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 7 12.000000 862.5000 71.8750
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 18 28.500000 1581.7500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 30 50.500000 3787.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 22 37.500000 2812.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 31 46.000000 3450.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 145 256.500000 14208.0000 55.3918
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 118 215.000000 16087.5000 74.8256
SCREEN-T1023-SCREENING 1 1.000000 50.0000 50.0000
Subtotal (Total Children Is Unduplicated) 228 667.000000 44339.7500 66.4764
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EI Services,Class #03
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 11 15.500000 387.5000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 379 1844.610000 92230.3600 49.9999
OCCT-97530-OT SESSION BY LICENSED OT 35 154.250000 11019.6200 71.4400
PHY-97110-PT SESSION BY LICENSED PT 47 275.500000 19667.4400 71.3882
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 38 168.000000 12001.9200 71.4400
Subtotal (Total Children Is Unduplicated) 479 2457.860000 135306.8400 55.0507
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Total 5396.110000 263442.3400 48.8208
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Number of Children (Unduplicated) With at Least One Service 984
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Center 53
Flag Claims Units Chgs Paid
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R 10 9.500000 454.8200 0.0000
U 0 0.000000 0.0000 0.0000
B 2523 2373.360000 112793.7300 336.5000
P 1794 1703.000000 77931.0200 77691.8200
D 32 32.750000 2033.5500 0.0000
S 0 0.000000 0.0000 0.0000
H 43 42.750000 3054.0600 0.0000
T 0 0.000000 0.0000 0.0000
1131 1197.750000 65705.9700 0.0000
Other 47 37.000000 1469.1900 0.0000
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Total 5580 5396.110000 263442.3400 78028.3200