CMS/EIP Fiscal Report Center: 06
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 1250 3209.750000 118742.7500 36.9944
Subtotal (Total Children Is Unduplicated) 1250 3209.750000 118742.7500 36.9944
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 4 5.000000 375.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 2 3.000000 225.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 4 5.000000 375.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 2 3.000000 166.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 207 322.000000 24150.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 38 58.000000 4350.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 68 103.500000 7762.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 193 305.500000 16955.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 4 6.500000 487.5000 75.0000
Subtotal (Total Children Is Unduplicated) 262 811.500000 54846.7500 67.5869
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 730 5112.000000 255600.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 121 151.750000 7587.5000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 25 99.000000 7072.5600 71.4400
OCCT-97530GT-OT SESSION BY LICENSED OT 3 2.000000 142.8800 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 11 50.000000 2860.0000 57.2000
OCCT-97530HMGT-OT SESSION BY OT ASST 1 1.500000 85.8000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 39 145.000000 10287.3600 70.9473
PHY-97110GT-PT SESSION BY LICENSED PT 1 0.500000 35.7200 71.4400
PHY-97110HM-PT SESSION BY PT ASST 7 14.500000 828.8200 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 37 121.500000 8679.9600 71.4400
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 4 3.500000 250.0400 71.4400
Subtotal (Total Children Is Unduplicated) 807 5701.250000 293430.6400 51.4678
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Total 9722.500000 467020.1400 48.0350
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Number of Children (Unduplicated) With at Least One Service 1364
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Center 06
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 0 0.000000 0.0000 0.0000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
11479 9722.500000 467020.1400 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 11479 9722.500000 467020.1400 0.0000