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: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 4.250000 157.2500 37.0000
Subtotal (Total Children Is Unduplicated) 1 4.250000 157.2500 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 1.000000 75.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 8 8.500000 1490.9600 175.4071
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 1.000000 55.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 1 1.000000 75.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 1 0.500000 37.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 4 3.500000 108.2500 30.9286
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 75 78.000000 11169.2900 143.1960
OCTH-97166-OT EVAL MODERATE COMPLEXITY 1 1.000000 51.0500 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 7 7.000000 275.3900 39.3414
PSTH-97162-PT EVAL MODERATE COMPLEXITY 3 3.000000 153.1500 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 3 3.000000 153.1500 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 5 5.000000 255.2500 51.0500
SPCH-92524-BEHAV & QUAL ANALYSIS OF VOICE AND RES 4 4.000000 204.2000 51.0500
Subtotal (Total Children Is Unduplicated) 97 116.500000 14103.6900 121.0617
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 5 48.000000 2400.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 22 83.000000 5270.7400 63.5029
OCCT-97530GT-OT SESSION BY LICENSED OT 2 3.500000 125.0400 35.7257
OCCT-97530HM-OT SESSION BY OT ASST 12 53.500000 3060.2000 57.2000
OCCT-97530HMGT-OT SESSION BY OT ASST 1 1.000000 57.2000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 20 93.500000 6655.8400 71.1855
PHY-97110GT-PT SESSION BY LICENSED PT 1 3.000000 165.2700 55.0900
PHY-97110HM-PT SESSION BY PT ASST 1 1.000000 57.1600 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 26 121.500000 8225.4800 67.6994
Subtotal (Total Children Is Unduplicated) 70 408.000000 26016.9300 63.7670
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Total 528.750000 40277.8700 76.1756
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Number of Children (Unduplicated) With at Least One Service 150
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Center 04
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 143 266.500000 23365.0700 15913.7200
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 12 46.000000 2329.8500 0.0000
T 0 0.000000 0.0000 0.0000
52 52.250000 3664.9600 81.4600
Other 71 164.000000 10917.9900 0.0000
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Total 278 528.750000 40277.8700 15995.1800