CMS/EIP Fiscal Report Center: 54
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 1222 3971.500000 146742.0000 36.9488
Subtotal (Total Children Is Unduplicated) 1222 3971.500000 146742.0000 36.9488
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 19 32.000000 2400.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 16 25.500000 1912.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 3 3.500000 262.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 16 29.500000 2212.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 28 46.500000 2580.7500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 131 201.300000 15060.0000 74.8137
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 74 103.000000 7725.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 25 33.500000 2512.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 170 257.000000 14263.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 76 125.000000 9375.0000 75.0000
SCREEN-T1023-SCREENING 8 8.000000 400.0000 50.0000
Subtotal (Total Children Is Unduplicated) 305 864.800000 58704.2500 67.8819
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 503 2679.250000 133925.0000 49.9860
OCCT-97530-OT SESSION BY LICENSED OT 80 360.500000 25739.8800 71.4005
PHY-97110-PT SESSION BY LICENSED PT 74 329.500000 23539.4800 71.4400
PHY-97110HM-PT SESSION BY PT ASST 4 4.000000 228.6400 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 57 282.250000 20163.9400 71.4400
SPL-92508-GROUP SPL SESSION PER CHILD 1 1.000000 13.8800 13.8800
Subtotal (Total Children Is Unduplicated) 683 3656.500000 203610.8200 55.6846
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Total 8492.800000 409057.0700 48.1652
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Number of Children (Unduplicated) With at Least One Service 1259
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Center 54
Flag Claims Units Chgs Paid
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R 110 106.000000 4369.7200 0.0000
U 0 0.000000 0.0000 0.0000
B 3252 2814.250000 134625.1800 145.4400
P 3180 2675.750000 118433.3200 117735.5900
D 95 96.000000 6555.7900 0.0000
S 0 0.000000 0.0000 0.0000
H 38 37.000000 2621.8400 37.0000
T 0 0.000000 0.0000 0.0000
2582 2688.050000 139579.5900 0.0000
Other 96 75.750000 2871.6300 27.7500
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Total 9353 8492.800000 409057.0700 117945.7800