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:TPIN
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 2 8.750000 323.7500 37.0000
Subtotal (Total Children Is Unduplicated) 2 8.750000 323.7500 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 10 12.500000 937.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 2 2.000000 150.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 12 16.500000 915.7500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 95 107.500000 8062.5000 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 38 45.000000 3375.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 130 159.000000 8824.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 3 6.000000 450.0000 75.0000
OCTH-97167-OT EVAL HIGH COMPLEXITY 6 6.000000 306.3000 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 3 3.000000 153.1500 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 12 12.000000 612.6000 51.0500
Subtotal (Total Children Is Unduplicated) 160 371.500000 23937.3000 64.4342
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 385 3248.000000 162400.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 14 83.250000 5947.3800 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 10 26.000000 1487.2000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 15 90.750000 6483.1800 71.4400
PHY-97110HM-PT SESSION BY PT ASST 8 26.000000 1486.1600 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 19 124.250000 8876.4200 71.4400
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 8 17.500000 1001.0000 57.2000
Subtotal (Total Children Is Unduplicated) 411 3615.750000 187681.3400 51.9066
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Total 3996.000000 211942.3900 53.0386
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Number of Children (Unduplicated) With at Least One Service 484
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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 0 0.000000 0.0000 0.0000
P 124 71.750000 4744.7300 4730.8600
D 0 0.000000 0.0000 0.0000
S 9 4.500000 321.4800 321.4800
H 0 0.000000 0.0000 0.0000
T 939 3241.000000 162656.5900 162656.5900
500 678.750000 44219.5900 22321.0800
Other 0 0.000000 0.0000 0.0000
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Total 1572 3996.000000 211942.3900 190030.0100