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:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 779 2030.750000 75137.7500 37.0000
Subtotal (Total Children Is Unduplicated) 779 2030.750000 75137.7500 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 7 12.000000 900.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 2 3.000000 225.0000 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 5 9.500000 527.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 88 154.000000 11550.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 42 73.000000 5475.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 14 25.500000 1912.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 60 102.000000 5661.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 20 37.500000 2812.5000 75.0000
OCTH-97165-OT EVAL LOW COMPLEXITY 1 1.000000 51.0500 51.0500
SCREEN-T1023-SCREENING 32 38.000000 1900.0000 50.0000
Subtotal (Total Children Is Unduplicated) 150 457.500000 31164.3000 68.1187
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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
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Total 2544.250000 109689.5700 43.1127
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Number of Children (Unduplicated) With at Least One Service 793
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Center 03
Flag Claims Units Chgs Paid
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R 43 32.000000 1221.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 3212 2452.750000 104620.8400 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
46 59.500000 3847.7300 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 3301 2544.250000 109689.5700 0.0000