CMS/EIP Fiscal Report Center: 52
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 519 1523.750000 56045.7500 36.7815
Subtotal (Total Children Is Unduplicated) 519 1523.750000 56045.7500 36.7815
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 10 18.500000 1387.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 6 12.000000 900.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 2 4.000000 300.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 5 10.000000 750.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 15 32.000000 1776.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 79 156.000000 11700.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 51 101.000000 7575.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 15 28.000000 2100.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 121 241.500000 13403.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 14 31.500000 2362.5000 75.0000
OCTH-97166-OT EVAL MODERATE COMPLEXITY 1 1.000000 51.0500 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 7 7.000000 357.3500 51.0500
PSTH-97162-PT EVAL MODERATE COMPLEXITY 3 3.000000 153.1500 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 1 1.000000 51.0500 51.0500
SCREEN-T1023-SCREENING 22 22.000000 1100.0000 50.0000
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 12 12.000000 612.6000 51.0500
SPCH-92524-BEHAV & QUAL ANALYSIS OF VOICE AND RES 1 1.000000 51.0500 51.0500
Subtotal (Total Children Is Unduplicated) 176 681.500000 44630.5000 65.4886
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 240 1289.750000 64487.5000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 55 265.000000 18903.1200 71.3325
OCCT-97530HM-OT SESSION BY OT ASST 16 84.250000 4819.1000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 35 245.250000 17470.6600 71.2361
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 101 545.250000 38952.6600 71.4400
SPL-92508-GROUP SPL SESSION PER CHILD 2 2.750000 38.1700 13.8800
Subtotal (Total Children Is Unduplicated) 374 2432.250000 144671.2100 59.4804
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Total 4637.500000 245347.4600 52.9051
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Number of Children (Unduplicated) With at Least One Service 591
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Center 52
Flag Claims Units Chgs Paid
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R 13 12.500000 547.0000 18.5000
U 0 0.000000 0.0000 0.0000
B 312 303.500000 14945.7300 0.0000
P 1807 1789.500000 81799.9500 81591.3500
D 0 0.000000 0.0000 0.0000
S 241 209.250000 7840.7500 0.0000
H 39 37.750000 2523.5800 74.9000
T 1 0.250000 9.2500 0.0000
1146 2284.500000 137671.9500 0.0000
Other 1 0.250000 9.2500 9.2500
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Total 3560 4637.500000 245347.4600 81694.0000