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:TPIN
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 1 3.250000 120.2500 37.0000
Subtotal (Total Children Is Unduplicated) 1 3.250000 120.2500 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 12 15.500000 1162.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 29 35.000000 2625.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 12 16.500000 915.7500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 87 96.000000 7200.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 5 9.500000 712.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 7 9.500000 712.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 128 162.500000 9018.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 2.000000 150.0000 75.0000
OCTH-97167-OT EVAL HIGH COMPLEXITY 16 16.000000 816.8000 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 5 6.000000 306.3000 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 11 11.000000 561.5500 51.0500
Subtotal (Total Children Is Unduplicated) 159 379.500000 24181.6500 63.7198
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 398 3208.000000 160400.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 15 67.250000 4804.3400 71.4400
PHY-97110-PT SESSION BY LICENSED PT 18 69.000000 4929.3600 71.4400
PHY-97110HM-PT SESSION BY PT ASST 3 38.000000 2172.0800 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 22 141.000000 10073.0400 71.4400
Subtotal (Total Children Is Unduplicated) 413 3523.250000 182378.8200 51.7644
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Total 3906.000000 206680.7200 52.9137
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Number of Children (Unduplicated) With at Least One Service 481
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Center 57
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 161 87.500000 6230.6100 6230.6100
D 0 0.000000 0.0000 0.0000
S 35 20.500000 1403.3500 1403.3500
H 0 0.000000 0.0000 0.0000
T 911 3202.000000 160857.3600 160857.3600
478 596.000000 38189.4000 16405.1510
Other 0 0.000000 0.0000 0.0000
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Total 1585 3906.000000 206680.7200 184896.4710