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:TPIN
Eligibility Filter:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 1 0.750000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 10 23.500000 795.5000 33.8511
Subtotal (Total Children Is Unduplicated) 10 24.250000 795.5000 32.8041
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 3 8.000000 510.0000 63.7500
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 4.000000 230.0000 57.5000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 3 6.000000 333.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 64 149.000000 9909.6500 66.5077
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 50 123.000000 8252.3100 67.0920
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 7 14.000000 1050.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 82 172.000000 8991.0000 52.2733
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 4 10.000000 677.7200 67.7720
OCTH-97166-OT EVAL MODERATE COMPLEXITY 2 3.000000 102.1000 34.0333
OCTH-97167-OT EVAL HIGH COMPLEXITY 2 2.000000 102.1000 51.0500
SCREEN-T1023-SCREENING 17 18.000000 850.0000 47.2222
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 10 10.000000 510.5000 51.0500
Subtotal (Total Children Is Unduplicated) 120 519.000000 31518.3800 60.7291
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 131 714.000000 34950.0000 48.9496
OCCT-97530-OT SESSION BY LICENSED OT 29 112.750000 7726.5300 68.5280
OCCT-97530HM-OT SESSION BY OT ASST 11 55.000000 3146.0000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 23 148.750000 9338.6000 62.7805
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 103 610.750000 40932.8700 67.0207
SPL-92508-GROUP SPL SESSION PER CHILD 1 4.000000 55.5200 13.8800
Subtotal (Total Children Is Unduplicated) 243 1645.250000 96149.5200 58.4407
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Total 2188.500000 128463.4000 58.6993
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Number of Children (Unduplicated) With at Least One Service 291
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Center 52
Flag Claims Units Chgs Paid
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R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 0 0.000000 0.0000 0.0000
P 80 112.000000 7689.6000 5090.0100
D 0 0.000000 0.0000 0.0000
S 5 5.000000 185.0000 0.0000
H 86 135.000000 9721.9200 0.0000
T 707 1078.750000 62164.6300 55578.3600
545 857.750000 48702.2500 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 1423 2188.500000 128463.4000 60668.3700