CMS/EIP Fiscal Report Center: 55
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 935 3336.500000 123450.5000 37.0000
Subtotal (Total Children Is Unduplicated) 935 3336.500000 123450.5000 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 9 18.000000 1350.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 7 14.000000 1050.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 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 167 334.666666 25100.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 115 230.000000 17250.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 8 16.000000 1200.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 46 94.000000 5217.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 45 89.946133 6745.9600 75.0000
OCTF-97168-OT RE-EVAL EST PLAN CARE 13 13.000000 663.6500 51.0500
OCTH-97166-OT EVAL MODERATE COMPLEXITY 3 3.000000 153.1500 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 5 5.000000 255.2500 51.0500
PSTF-97164-PT RE-EVAL EST PLAN CARE 2 2.000000 102.1000 51.0500
PSTH-97162-PT EVAL MODERATE COMPLEXITY 1 1.000000 51.0500 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 1 1.000000 51.0500 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 16 16.000000 816.8000 51.0500
Subtotal (Total Children Is Unduplicated) 268 845.612799 60528.0100 71.5789
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EI Services,Class #03
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 4 13.250000 331.2500 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 306 1780.000000 89000.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 78 363.500000 25968.4400 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 97 472.000000 26998.4000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 49 206.440090 14748.0800 71.4400
PHY-97110HM-PT SESSION BY PT ASST 32 133.900105 7653.7300 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 141 809.753920 57848.8200 71.4400
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 1 2.000000 114.4000 57.2000
Subtotal (Total Children Is Unduplicated) 546 3780.844115 222663.1200 58.8924
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Total 7962.956914 406641.6300 51.0667
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Number of Children (Unduplicated) With at Least One Service 971
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Center 55
Flag Claims Units Chgs Paid
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R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 1751 1510.000000 63338.7500 96.2500
P 2913 2457.750000 99682.2500 108155.4800
D 0 0.000000 0.0000 0.0000
S 2 2.666666 200.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 1 0.750000 27.7500 27.7500
3832 3991.790248 243392.8800 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 8499 7962.956914 406641.6300 108279.4800