CMS/EIP Fiscal Report Center: 06
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 1212 2766.750000 102360.5000 36.9967
Subtotal (Total Children Is Unduplicated) 1212 2766.750000 102360.5000 36.9967
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 2 3.500000 262.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 3 5.500000 305.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 90 138.000000 10350.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 34 51.500000 3862.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 88 130.500000 9787.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 208 314.000000 17427.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 130 212.500000 15937.5000 75.0000
Subtotal (Total Children Is Unduplicated) 284 857.500000 58082.2500 67.7344
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 707 5572.500000 278625.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 39 144.500000 10323.0800 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 14 53.000000 3031.5600 57.1992
PHY-97110-PT SESSION BY LICENSED PT 37 123.000000 8751.4000 71.1496
PHY-97110HM-PT SESSION BY PT ASST 6 15.000000 857.4000 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 38 154.000000 11001.7600 71.4400
Subtotal (Total Children Is Unduplicated) 792 6062.000000 312590.2000 51.5655
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Total 9686.250000 473032.9500 48.8355
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Number of Children (Unduplicated) With at Least One Service 1354
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Center 06
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 0 0.000000 0.0000 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
11139 9686.250000 473032.9500 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 11139 9686.250000 473032.9500 0.0000