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
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 1434 6526.250000 241471.2500 37.0000
Subtotal (Total Children Is Unduplicated) 1434 6526.250000 241471.2500 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 14 10.500000 787.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 23 20.000000 1500.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 1.000000 75.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 38 44.000000 3300.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 31 28.500000 1581.7500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 107 79.000000 5925.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 165 131.000000 9825.0000 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 302 273.500000 15179.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 131 108.500000 8137.5000 75.0000
OCTH-97166-OT EVAL MODERATE COMPLEXITY 7 7.000000 357.3500 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 25 25.000000 1276.2500 51.0500
PSTF-97164-PT RE-EVAL EST PLAN CARE 2 2.000000 102.1000 51.0500
PSTH-97162-PT EVAL MODERATE COMPLEXITY 8 8.000000 408.4000 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 16 16.000000 816.8000 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 2 2.000000 102.1000 51.0500
SPCH-92524-BEHAV & QUAL ANALYSIS OF VOICE AND RES 1 1.000000 51.0500 51.0500
Subtotal (Total Children Is Unduplicated) 406 757.500000 49462.5500 65.2971
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1010 9458.000000 472900.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 20 86.000000 6143.8400 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 50 303.000000 17331.6000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 33 175.500000 12537.7200 71.4400
PHY-97110HM-PT SESSION BY PT ASST 44 286.000000 16347.7600 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 4 23.500000 1678.8400 71.4400
Subtotal (Total Children Is Unduplicated) 1061 10332.00000 526939.7600 51.0008
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Total 17615.750000 817873.5600 46.4285
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Number of Children (Unduplicated) With at Least One Service 1582
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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 2720 10354.500000 527702.1600 0.0000
T 0 0.000000 0.0000 0.0000
202 168.500000 11148.7500 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 7592 17615.750000 817873.5600 179600.1900