CMS/EIP Fiscal Report Center: 01
Services beginning 01/01/2020 ending 03/31/2020 Date of Report:05/15/2020 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 1892 6170.750000 228317.7500 37.0000
Subtotal (Total Children Is Unduplicated) 1892 6170.750000 228317.7500 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 12 19.000000 1425.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 0.500000 37.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 16 35.000000 2625.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 12 32.000000 1776.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 87 140.500000 10455.4000 74.4157
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 13 18.000000 1350.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 8 11.500000 862.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 204 309.500000 17177.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 172 281.000000 21075.0000 75.0000
PSTF-97164-PT RE-EVAL EST PLAN CARE 1 1.000000 51.0500 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 1 1.000000 51.0500 51.0500
SPCH-92521-EVAL OF SPEECH FLUENCY 1 1.000000 51.0500 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 2 2.000000 102.1000 51.0500
SPCH-92610-EVAL OF ORAL,PHARYNGEAL SWALLOWING FUNC 1 1.000000 48.9400 48.9400
Subtotal (Total Children Is Unduplicated) 290 853.000000 57087.8400 66.9260
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 132 496.500000 24825.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 23 25.250000 1262.5000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 28 154.500000 11037.4800 71.4400
OCCT-97530GT-OT SESSION BY LICENSED OT 11 10.500000 739.4400 70.4229
PHY-97110-PT SESSION BY LICENSED PT 36 181.000000 12930.6400 71.4400
PHY-97110GT-PT SESSION BY LICENSED PT 6 9.000000 642.9600 71.4400
PHY-97110HM-PT SESSION BY PT ASST 1 1.000000 57.1600 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 36 151.250000 10805.3000 71.4400
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 6 6.500000 464.3600 71.4400
Subtotal (Total Children Is Unduplicated) 214 1035.500000 62764.8400 60.6131
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Total 8059.250000 348170.4300 43.2013
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Number of Children (Unduplicated) With at Least One Service 1904
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Center 01
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 2 1.750000 64.7500 64.7500
D 162 166.750000 9100.6000 0.0000
S 2 1.500000 89.9400 0.0000
H 11019 7526.750000 315686.1400 315265.2400
T 0 0.000000 0.0000 0.0000
1 1.500000 112.5000 0.0000
Other 230 361.000000 23116.5000 0.0000
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Total 11416 8059.250000 348170.4300 315329.9900