CMS/EIP Fiscal Report Center: 07
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
CASE-CASE-NON-TCM CASE MANAGEMENT 2 0.500000 18.5000 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 6 7.750000 277.5000 35.8065
Subtotal (Total Children Is Unduplicated) 6 8.250000 296.0000 35.8788
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Screening, Eval, and Assessment,Class #02
EVAL-96111-DEVELOPMENTAL EVALUATION 1 1.000000 50.0000 50.0000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 31 60.667000 4550.0250 75.0000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 25 43.420400 3256.5300 75.0000
OCTH-97166-OT EVAL MODERATE COMPLEXITY 1 1.000000 51.0500 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 1 1.000000 51.0500 51.0500
PSTH-97162-PT EVAL MODERATE COMPLEXITY 1 1.000000 51.0500 51.0500
SCREEN-T1023-SCREENING 2 2.000000 100.0000 50.0000
SPCH-92522-EVAL OF SPCH SOUND PROD 1 1.000000 51.0500 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 16 16.000000 816.8000 51.0500
Subtotal (Total Children Is Unduplicated) 63 127.087400 8977.5550 70.6408
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EI Services,Class #03
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 1 1.250000 0.0000 0.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 33 160.000000 8000.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 1 1.750000 87.5000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 17 82.500000 5893.8000 71.4400
OCCT-97530GT-OT SESSION BY LICENSED OT 1 2.000000 142.8800 71.4400
PHY-97110-PT SESSION BY LICENSED PT 10 46.000000 3286.2400 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 101 662.250000 47261.1400 71.3645
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 8 10.750000 767.9800 71.4400
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 1 2.000000 114.4000 57.2000
Subtotal (Total Children Is Unduplicated) 142 968.500000 65553.9400 67.6861
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Total 1103.837400 74827.4950 67.7885
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Number of Children (Unduplicated) With at Least One Service 192
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Center 07
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 2 0.500000 18.5000 0.0000
P 439 1004.087400 67897.9450 67897.9200
D 17 33.000000 2451.0500 0.0000
S 3 2.250000 96.2500 0.0000
H 19 37.000000 2751.0500 0.0000
T 0 0.000000 0.0000 0.0000
23 27.000000 1612.7000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 503 1103.837400 74827.4950 67897.9200