CMS/EIP Fiscal Report Center: 55
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 906 2929.250000 108337.0000 36.9846
Subtotal (Total Children Is Unduplicated) 906 2929.250000 108337.0000 36.9846
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 8 16.000000 1200.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 12 24.000000 1800.0000 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 8 16.000000 888.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 199 402.000000 30150.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 156 311.871733 23390.3800 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 66 132.000000 9900.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 57 114.000000 6327.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 10 19.303467 1447.7600 75.0000
OCTF-97168-OT RE-EVAL EST PLAN CARE 5 5.000000 255.2500 51.0500
OCTH-97165-OT EVAL LOW COMPLEXITY 1 1.000000 51.0500 51.0500
OCTH-97166-OT EVAL MODERATE COMPLEXITY 1 1.000000 51.0500 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 21 21.000000 1072.0500 51.0500
PSTF-97164-PT RE-EVAL EST PLAN CARE 1 1.000000 51.0500 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 4 4.000000 204.2000 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 12 14.000000 714.7000 51.0500
Subtotal (Total Children Is Unduplicated) 313 1086.175200 77802.4900 71.6298
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EI Services,Class #03
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 4 15.750000 393.7500 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 364 2476.750000 123837.5000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 79 463.677212 33125.1000 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 108 581.750000 33276.1000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 42 234.000000 16699.1000 71.3637
PHY-97110HM-PT SESSION BY PT ASST 29 144.125262 8238.2000 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 144 992.000000 70868.4800 71.4400
SPL-92508-GROUP SPL SESSION PER CHILD 1 3.000000 41.6400 13.8800
Subtotal (Total Children Is Unduplicated) 598 4911.052474 286479.8700 58.3337
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Total 8926.477674 472619.3600 52.9458
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Number of Children (Unduplicated) With at Least One Service 961
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Center 55
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 1025 863.250000 36804.5000 0.0000
P 3084 2715.750000 112422.5000 112153.0000
D 0 0.000000 0.0000 0.0000
S 1 1.303467 97.7600 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
5088 5346.174207 323294.6000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 9198 8926.477674 472619.3600 112153.0000