CMS/EIP Fiscal Report Center: 51
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 373 1032.750000 38165.5000 36.9552
Subtotal (Total Children Is Unduplicated) 373 1032.750000 38165.5000 36.9552
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 3 3.000000 225.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 1.000000 75.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 4 4.000000 222.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 52 52.000000 3900.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 14 14.000000 1050.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 1 1.000000 75.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 66 66.500000 3690.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 7 7.000000 525.0000 75.0000
OCTH-97165-OT EVAL LOW COMPLEXITY 2 2.000000 102.1000 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 6 6.000000 306.3000 51.0500
PSTH-97161-PT EVAL LOW COMPLEXITY 1 1.000000 51.0500 51.0500
PSTH-97162-PT EVAL MODERATE COMPLEXITY 1 1.000000 51.0500 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 2 2.000000 102.1000 51.0500
SCREEN-T1023-SCREENING 7 7.000000 350.0000 50.0000
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 1 1.000000 51.0500 51.0500
Subtotal (Total Children Is Unduplicated) 100 168.500000 10776.4000 63.9549
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 137 800.750000 39987.5000 49.9376
OCCT-97530-OT SESSION BY LICENSED OT 44 162.000000 11573.2800 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 40 157.000000 8980.4000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 26 130.000000 9164.3200 70.4948
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 108 649.500000 45552.0000 70.1339
SPL-92508-GROUP SPL SESSION PER CHILD 5 18.000000 249.8400 13.8800
Subtotal (Total Children Is Unduplicated) 284 1917.250000 115507.3400 60.2464
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Total 3118.500000 164449.2400 52.7334
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Number of Children (Unduplicated) With at Least One Service 494
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Center 51
Flag Claims Units Chgs Paid
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R 5 5.000000 277.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 636 422.000000 16791.2500 0.0000
P 42 43.000000 2249.0000 2379.5000
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
1720 2648.500000 145131.4900 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 2403 3118.500000 164449.2400 2379.5000