CMS/EIP Fiscal Report Center: 04
Services beginning 10/01/2019 ending 12/31/2019 Date of Report:02/01/2020 Page: 1
List order: No List
Payclass Filters:MED
Bill Flag Filter:RBPU
Eligibility Filter:All
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 1434 6523.250000 241360.2500 37.0000
Subtotal (Total Children Is Unduplicated) 1434 6523.250000 241360.2500 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 11 8.500000 637.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 17 15.000000 1125.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 30 34.000000 2550.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 23 22.500000 1248.7500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 84 62.500000 4687.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 124 100.000000 7500.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 1 0.500000 37.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 230 209.000000 11599.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 98 79.000000 5925.0000 75.0000
OCTH-97167-OT EVAL HIGH COMPLEXITY 1 1.000000 51.0500 51.0500
Subtotal (Total Children Is Unduplicated) 276 532.000000 35361.8000 66.4695
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1 3.000000 150.0000 50.0000
OCCT-97530HM-OT SESSION BY OT ASST 1 2.000000 114.4000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 3 5.500000 392.9200 71.4400
PHY-97110HM-PT SESSION BY PT ASST 5 20.000000 1143.2000 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 1 7.000000 500.0800 71.4400
Subtotal (Total Children Is Unduplicated) 10 37.500000 2300.6000 61.3493
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Total 7092.750000 279022.6500 39.3391
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Number of Children (Unduplicated) With at Least One Service 1437
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Center 04
Flag Claims Units Chgs Paid
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R 516 792.250000 29313.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 1109 1654.250000 65618.0000 46.2500
P 3045 4646.250000 184091.4000 179553.9400
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
0 0.000000 0.0000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 4670 7092.750000 279022.6500 179600.1900