CMS/EIP Fiscal Report Center: 03
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:Part C (excluding not eligible)
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 711 1825.250000 67534.2500 37.0000
Subtotal (Total Children Is Unduplicated) 711 1825.250000 67534.2500 37.0000
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 3 5.500000 412.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 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 67 121.500000 9112.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 35 62.500000 4687.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 9 16.500000 1237.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 46 80.500000 4467.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 15 28.500000 2137.5000 75.0000
OCTH-97165-OT EVAL LOW COMPLEXITY 1 1.000000 51.0500 51.0500
SCREEN-T1023-SCREENING 31 37.000000 1850.0000 50.0000
Subtotal (Total Children Is Unduplicated) 119 361.000000 24478.3000 67.8069
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 16 24.750000 1237.5000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 2 18.000000 1271.6800 70.6489
OCCT-97530HM-OT SESSION BY OT ASST 1 0.750000 42.9000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 1 2.000000 142.8800 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 4 10.500000 692.5600 65.9581
Subtotal (Total Children Is Unduplicated) 24 56.000000 3387.5200 60.4914
-----------------------------------------------------------------------------------------------------------------------
Total 2242.250000 95400.0700 42.5466
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 725
-----------------------------------------------------------------------------------------------------------------------
Center 03
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 41 31.500000 1202.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 2945 2153.250000 90460.8400 0.0000
P 0 0.000000 0.0000 0.0000
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
45 57.500000 3736.7300 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 3031 2242.250000 95400.0700 0.0000