CMS/EIP Fiscal Report Center: 57
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 1002 4093.750000 151468.7500 37.0000
Subtotal (Total Children Is Unduplicated) 1002 4093.750000 151468.7500 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 14 12.500000 937.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 3 3.000000 225.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 17 19.000000 1054.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 165 170.500000 12787.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 76 88.000000 6600.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 237 277.500000 15401.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 2 4.000000 300.0000 75.0000
OCTH-97167-OT EVAL HIGH COMPLEXITY 14 16.000000 816.8000 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 17 17.000000 867.8500 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 24 25.000000 1276.2500 51.0500
Subtotal (Total Children Is Unduplicated) 291 634.500000 40416.6500 63.6984
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 840 6430.000000 321500.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 29 181.750000 12984.2200 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 22 96.750000 5534.1000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 17 79.000000 5643.7600 71.4400
PHY-97110HM-PT SESSION BY PT ASST 24 121.750000 6959.2300 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 27 87.000000 6215.2800 71.4400
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 24 124.750000 7135.7000 57.2000
Subtotal (Total Children Is Unduplicated) 887 7121.000000 365972.2900 51.3934
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Total 11849.250000 557857.6900 47.0796
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Number of Children (Unduplicated) With at Least One Service 1154
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Center 57
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 222 266.000000 11344.7500 18.5000
P 3749 4396.250000 177018.7500 173275.0000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
2129 7187.000000 369494.1900 369494.1900
Other 0 0.000000 0.0000 0.0000
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Total 6100 11849.250000 557857.6900 542787.6900