CMS/EIP Fiscal Report Center: 10
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 2332 6869.250000 254162.2500 37.0000
Subtotal (Total Children Is Unduplicated) 2332 6869.250000 254162.2500 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 6 10.000000 750.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 3 6.000000 450.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 2 4.000000 300.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 9 16.500000 915.7500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 257 459.500000 34462.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 125 216.000000 16170.7500 74.8646
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 64 100.000000 7500.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 282 507.000000 28138.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 34 65.000000 4875.0000 75.0000
OCTH-97166-OT EVAL MODERATE COMPLEXITY 1 1.000000 51.0500 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 4 4.000000 204.2000 51.0500
PSTH-97161-PT EVAL LOW COMPLEXITY 1 1.000000 51.0500 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 5 6.000000 306.3000 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 6 6.000000 306.3000 51.0500
SPCH-92524-BEHAV & QUAL ANALYSIS OF VOICE AND RES 3 3.000000 153.1500 51.0500
SPCH-92610-EVAL OF ORAL,PHARYNGEAL SWALLOWING FUNC 1 1.000000 48.9400 48.9400
Subtotal (Total Children Is Unduplicated) 396 1406.000000 94683.4900 67.3425
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 3 31.000000 3014.4600 97.2406
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1207 11625.50000 581275.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 169 701.000000 50002.2400 71.3299
OCCT-97530HM-OT SESSION BY OT ASST 13 42.250000 2416.7000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 209 836.500000 59725.2400 71.3990
PHY-97110HM-PT SESSION BY PT ASST 9 11.000000 628.7600 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 195 1049.500000 74839.3900 71.3096
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 1 2.000000 114.4000 57.2000
SPL-92508-GROUP SPL SESSION PER CHILD 3 5.000000 69.4000 13.8800
Subtotal (Total Children Is Unduplicated) 1434 14303.75000 772085.5900 53.9778
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Total 22579.000000 1120931.3300 49.6449
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Number of Children (Unduplicated) With at Least One Service 2531
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Center 10
Flag Claims Units Chgs Paid
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R 189 163.750000 6058.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 3617 2974.500000 122701.0000 18.5000
P 6180 5104.000000 218829.3000 217635.9580
D 8 9.750000 360.7500 0.0000
S 34 86.000000 4300.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
4575 14240.500000 768663.0300 0.0000
Other 1 0.500000 18.5000 0.0000
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Total 14604 22579.000000 1120931.3300 217654.4580