CMS/EIP Fiscal Report Center: 51
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 376 1014.500000 37388.5000 36.8541
Subtotal (Total Children Is Unduplicated) 376 1014.500000 37388.5000 36.8541
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 4 4.000000 300.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 1.000000 75.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 7 7.000000 388.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 50 53.000000 3827.0000 72.2075
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 4 4.000000 300.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 13 13.000000 975.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 3 3.000000 225.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 56 57.500000 3191.2500 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 1 1.000000 55.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 15 16.000000 1200.0000 75.0000
OCTH-97165-OT EVAL LOW COMPLEXITY 1 1.000000 51.0500 51.0500
OCTH-97166-OT EVAL MODERATE COMPLEXITY 1 1.000000 51.0500 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 12 12.000000 612.6000 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 8 8.000000 408.4000 51.0500
Subtotal (Total Children Is Unduplicated) 110 184.500000 11811.4000 64.0184
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 138 797.000000 39850.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 3 8.000000 400.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 45 178.500000 12752.0400 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 55 240.250000 13685.1000 56.9619
PHY-97110-PT SESSION BY LICENSED PT 21 93.250000 6661.7800 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 118 626.000000 44548.7600 71.1642
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 4 8.500000 549.6800 64.6682
Subtotal (Total Children Is Unduplicated) 295 1951.500000 118447.3600 60.6955
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Total 3150.500000 167647.2600 53.2129
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Number of Children (Unduplicated) With at Least One Service 492
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Center 51
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 1114 828.750000 34664.8300 0.0000
P 381 307.500000 12088.5000 11939.7500
D 14 12.500000 538.0000 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
711 2000.750000 120284.4900 0.0000
Other 1 1.000000 71.4400 0.0000
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Total 2221 3150.500000 167647.2600 11939.7500