CMS/EIP Fiscal Report Center: 09
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 1180 4068.500000 150534.5000 37.0000
Subtotal (Total Children Is Unduplicated) 1180 4068.500000 150534.5000 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 5 9.000000 675.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 2 4.000000 300.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 9 15.500000 1162.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 2 4.000000 300.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 6 11.000000 610.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 87 148.000000 11100.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 63 101.500000 7612.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 2 4.000000 300.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 89 151.500000 11362.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 133 234.000000 12987.0000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 2 4.000000 222.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 75 120.000000 9000.0000 75.0000
Subtotal (Total Children Is Unduplicated) 236 806.500000 55632.0000 68.9795
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 824 5694.000000 284600.0000 49.9824
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 117 144.000000 7200.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 53 326.000000 23289.4400 71.4400
OCCT-97530GT-OT SESSION BY LICENSED OT 9 15.000000 1071.6000 71.4400
OCCT-97530TLGT-OT SESSION BY LICENSED OT 1 1.000000 71.4400 71.4400
PHY-97110-PT SESSION BY LICENSED PT 74 489.000000 34934.1600 71.4400
PHY-97110GT-PT SESSION BY LICENSED PT 6 10.000000 714.4000 71.4400
PHY-97110TLGT-PT SESSION BY LICENSED PT 3 3.000000 214.3200 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 161 1273.000000 90900.2400 71.4063
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 20 35.000000 2500.4000 71.4400
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 1 2.000000 142.8800 71.4400
SPL-92508-GROUP SPL SESSION PER CHILD 1 3.000000 41.6400 13.8800
Subtotal (Total Children Is Unduplicated) 980 7995.000000 445680.5200 55.7449
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Total 12870.000000 651847.0200 50.6486
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Number of Children (Unduplicated) With at Least One Service 1383
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Center 09
Flag Claims Units Chgs Paid
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R 1 2.000000 150.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 181 176.750000 6927.7500 0.0000
P 4204 4423.250000 178742.2500 178742.2500
D 52 47.500000 1757.5000 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
2698 7926.000000 442630.5200 0.0000
Other 173 294.500000 21639.0000 0.0000
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Total 7309 12870.000000 651847.0200 178742.2500