CMS/EIP Fiscal Report Center: 09
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 1149 4043.500000 149591.0000 36.9954
Subtotal (Total Children Is Unduplicated) 1149 4043.500000 149591.0000 36.9954
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 5 9.500000 712.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 2 3.500000 262.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 3 4.500000 337.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 4 6.500000 487.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 6 11.000000 610.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 71 117.500000 8812.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 58 101.500000 7612.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 65 110.000000 8211.0000 74.6455
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 124 221.000000 12265.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 61 98.500000 7387.5000 75.0000
Subtotal (Total Children Is Unduplicated) 202 683.500000 46699.5000 68.3241
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 818 5466.250000 273266.5000 49.9916
OCCT-97530-OT SESSION BY LICENSED OT 53 338.000000 24146.7200 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 1 5.000000 286.0000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 86 619.000000 44221.3600 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 159 1262.500000 90193.0000 71.4400
Subtotal (Total Children Is Unduplicated) 983 7690.750000 432113.5800 56.1861
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Total 12417.750000 628404.0800 50.6053
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Number of Children (Unduplicated) With at Least One Service 1350
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Center 09
Flag Claims Units Chgs Paid
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R 2 0.500000 18.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 167 170.000000 6787.7500 120.2500
P 4047 4414.250000 176548.0000 176548.0000
D 5 3.500000 129.5000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 2 2.500000 129.5000 259.0000
2420 7578.500000 426826.0800 0.0000
Other 143 248.500000 17964.7500 0.0000
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Total 6786 12417.750000 628404.0800 176927.2500