CMS/EIP Fiscal Report Center: 52
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 465 1361.000000 50255.2500 36.9252
Subtotal (Total Children Is Unduplicated) 465 1361.000000 50255.2500 36.9252
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 11 22.000000 1650.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 9 18.000000 1350.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 2 4.000000 300.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 3 6.000000 450.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 10 20.000000 1110.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 72 141.000000 10575.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 48 96.000000 7200.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 19 37.500000 2812.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 86 172.000000 9518.2500 55.3387
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 11 20.500000 1537.5000 75.0000
OCTH-97166-OT EVAL MODERATE COMPLEXITY 3 3.000000 153.1500 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 3 3.000000 153.1500 51.0500
PSTH-97162-PT EVAL MODERATE COMPLEXITY 1 1.000000 51.0500 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 2 2.000000 102.1000 51.0500
SCREEN-T1023-SCREENING 30 30.000000 1500.0000 50.0000
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 13 13.000000 663.6500 51.0500
Subtotal (Total Children Is Unduplicated) 144 589.000000 39126.3500 66.4284
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 249 1276.500000 63825.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 27 27.000000 1350.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 59 295.250000 21078.4200 71.3918
OCCT-97530GT-OT SESSION BY LICENSED OT 1 1.000000 71.4400 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 17 90.000000 5148.0000 57.2000
OCCT-97530HMGT-OT SESSION BY OT ASST 2 1.750000 100.1000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 36 245.500000 17538.5200 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 102 493.250000 35237.7800 71.4400
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 8 8.500000 607.2400 71.4400
Subtotal (Total Children Is Unduplicated) 378 2438.750000 144956.5000 59.4389
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Total 4388.750000 234338.1000 53.3952
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Number of Children (Unduplicated) With at Least One Service 544
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Center 52
Flag Claims Units Chgs Paid
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R 5 3.250000 120.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 324 303.750000 15124.9100 150.0000
P 1382 1396.750000 65254.1600 65080.6200
D 0 0.000000 0.0000 0.0000
S 483 468.250000 17888.2500 233.2500
H 35 42.000000 2818.6800 447.7600
T 1 3.000000 214.3200 0.0000
1112 2171.750000 132917.5300 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 3342 4388.750000 234338.1000 65911.6300