CMS/EIP Fiscal Report Center: 01
Services beginning 10/01/2019 ending 12/31/2019 Date of Report:02/01/2020 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 1774 5438.250000 201215.2500 37.0000
Subtotal (Total Children Is Unduplicated) 1774 5438.250000 201215.2500 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 10 17.500000 1312.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 1.500000 112.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 25 60.000000 4500.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 10 17.000000 943.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 132 199.000000 14925.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 18 24.500000 1837.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 23 33.000000 2475.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 325 512.000000 28416.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 233 392.500000 29437.5000 75.0000
OCTH-97166-OT EVAL MODERATE COMPLEXITY 1 1.000000 51.0500 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 2 2.000000 102.1000 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 2 2.000000 102.1000 51.0500
SPCH-92521-EVAL OF SPEECH FLUENCY 1 1.000000 51.0500 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 2 2.000000 102.1000 51.0500
Subtotal (Total Children Is Unduplicated) 423 1265.000000 84367.9000 66.6940
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 153 539.500000 26912.5000 49.8842
OCCT-97530-OT SESSION BY LICENSED OT 27 133.000000 9501.5200 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 2 4.000000 228.8000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 39 215.000000 15359.6000 71.4400
PHY-97110HM-PT SESSION BY PT ASST 5 14.000000 800.2400 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 31 125.500000 8965.7200 71.4400
SPL-92508-GROUP SPL SESSION PER CHILD 4 10.000000 138.8000 13.8800
Subtotal (Total Children Is Unduplicated) 229 1041.000000 61907.1800 59.4690
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Total 7744.250000 347490.3300 44.8708
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Number of Children (Unduplicated) With at Least One Service 1798
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Center 01
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 202 201.250000 14319.3000 0.0000
P 2 2.000000 100.0000 100.0000
D 93 94.500000 4788.1000 0.0000
S 2531 1929.000000 84774.8700 0.0000
H 6798 4966.750000 208517.6200 208392.6000
T 0 0.000000 0.0000 0.0000
13 6.750000 284.1900 0.0000
Other 339 544.000000 34706.2500 0.0000
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Total 9978 7744.250000 347490.3300 208492.6000