CMS/EIP Fiscal Report Center: 04
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 1437 6347.500000 234857.5000 37.0000
Subtotal (Total Children Is Unduplicated) 1437 6347.500000 234857.5000 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 18 12.500000 937.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 17 13.000000 975.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 29 36.500000 2737.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 37 45.000000 2497.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 94 67.000000 5025.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 125 94.000000 7050.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 252 221.000000 12265.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 112 93.000000 6975.0000 75.0000
OCTH-97166-OT EVAL MODERATE COMPLEXITY 2 2.000000 102.1000 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 21 21.000000 1072.0500 51.0500
OCTH-97167GT-OT EVAL HIGH COMPLEXITY 1 1.000000 51.0500 51.0500
PSTH-97162-PT EVAL MODERATE COMPLEXITY 18 18.000000 918.9000 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 14 14.000000 714.7000 51.0500
SPCH-92522-EVAL OF SPCH SOUND PROD 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-92524-BEHAV & QUAL ANALYSIS OF VOICE AND RES 2 2.000000 102.1000 51.0500
Subtotal (Total Children Is Unduplicated) 352 643.000000 41577.0500 64.6610
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 962 8739.000000 436870.0000 49.9908
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 36 53.000000 2650.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 22 81.500000 5822.3600 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 54 316.000000 18075.2000 57.2000
OCCT-97530HMGT-OT SESSION BY OT ASST 1 2.000000 114.4000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 27 147.000000 10501.6800 71.4400
PHY-97110GT-PT SESSION BY LICENSED PT 2 3.000000 214.3200 71.4400
PHY-97110HM-PT SESSION BY PT ASST 43 347.000000 19834.5200 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 6 21.500000 1535.9600 71.4400
Subtotal (Total Children Is Unduplicated) 1025 9710.000000 495618.4400 51.0421
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Total 16700.500000 772052.9900 46.2293
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Number of Children (Unduplicated) With at Least One Service 1577
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Center 04
Flag Claims Units Chgs Paid
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R 37 50.750000 1877.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 1268 1802.000000 70009.5000 101.7500
P 2759 4278.000000 166826.6700 164337.3100
D 1 1.000000 75.0000 0.0000
S 2 4.000000 148.0000 0.0000
H 2810 9739.500000 496606.5700 0.0000
T 0 0.000000 0.0000 0.0000
665 819.250000 36287.5000 0.0000
Other 4 6.000000 222.0000 0.0000
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Total 7546 16700.500000 772052.9900 164439.0600