CMS/EIP Fiscal Report Center: 57
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 1025 4098.500000 151644.5000 37.0000
Subtotal (Total Children Is Unduplicated) 1025 4098.500000 151644.5000 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 13 14.500000 1087.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 24 27.500000 2062.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 19 21.000000 1165.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 151 163.000000 12205.5000 74.8804
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 6 11.000000 825.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 59 64.500000 4837.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 244 292.500000 16233.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 4 7.000000 525.0000 75.0000
OCTH-97167-OT EVAL HIGH COMPLEXITY 4 4.000000 204.2000 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 2 2.000000 102.1000 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 1 1.000000 51.0500 51.0500
Subtotal (Total Children Is Unduplicated) 264 608.000000 39299.6000 64.6375
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 796 6761.000000 338050.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 9 31.000000 2214.6400 71.4400
PHY-97110-PT SESSION BY LICENSED PT 5 29.500000 2107.4800 71.4400
PHY-97110HM-PT SESSION BY PT ASST 1 17.000000 971.7200 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 4 12.000000 857.2800 71.4400
Subtotal (Total Children Is Unduplicated) 803 6850.500000 344201.1200 50.2447
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Total 11557.000000 535145.2200 46.3049
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Number of Children (Unduplicated) With at Least One Service 1141
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Center 57
Flag Claims Units Chgs Paid
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R 1 1.000000 37.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 379 458.250000 17763.7500 55.0000
P 3571 4200.750000 169972.2500 166599.0200
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 12 14.500000 1087.5000 0.0000
T 1 1.000000 50.0000 50.0000
1935 6881.000000 346216.2200 346200.8900
Other 1 0.500000 18.5000 18.5000
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Total 5900 11557.000000 535145.2200 512923.4100