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:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 1220 4273.000000 158008.5000 36.9784
Subtotal (Total Children Is Unduplicated) 1220 4273.000000 158008.5000 36.9784
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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 5 9.500000 712.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 5 8.500000 637.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 5 8.500000 637.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 10 19.000000 1054.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 94 156.000000 11700.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 77 131.500000 9862.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 88 149.000000 11097.0000 74.4765
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 167 295.500000 16400.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 84 133.500000 10012.5000 75.0000
Subtotal (Total Children Is Unduplicated) 273 920.500000 62826.7500 68.2529
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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 12884.250000 652948.8300 50.6781
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Number of Children (Unduplicated) With at Least One Service 1423
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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 178 187.250000 7501.0000 120.2500
P 4251 4763.000000 193056.5000 193056.5000
D 6 5.500000 279.5000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 3 4.500000 240.5000 425.5000
2424 7585.500000 427351.0800 0.0000
Other 197 338.000000 24501.7500 0.0000
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Total 7061 12884.250000 652948.8300 193602.2500