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:TPIN
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 4 10.250000 379.2500 37.0000
Subtotal (Total Children Is Unduplicated) 4 10.250000 379.2500 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 4 6.500000 487.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 5 10.000000 750.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 2.000000 150.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 6 12.000000 666.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 72 156.500000 11032.3400 70.4942
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 53 116.000000 8172.4000 70.4517
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 25 56.500000 3815.6500 67.5336
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 85 172.500000 9351.7500 54.2130
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 6 11.000000 825.0000 75.0000
OCTH-97166-OT EVAL MODERATE COMPLEXITY 3 3.000000 153.1500 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
PSTH-97163-PT EVAL HIGH COMPLEXITY 3 3.000000 153.1500 51.0500
SCREEN-T1023-SCREENING 18 19.000000 900.0000 47.3684
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 9 9.000000 459.4500 51.0500
Subtotal (Total Children Is Unduplicated) 128 579.000000 37018.4900 63.9352
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 122 623.500000 31040.0000 49.7835
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 18 18.000000 900.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 31 116.250000 7733.3800 66.5237
OCCT-97530HM-OT SESSION BY OT ASST 12 65.500000 3746.6000 57.2000
OCCT-97530HMGT-OT SESSION BY OT ASST 2 3.000000 171.6000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 29 154.500000 9519.3800 61.6141
PHY-97110GT-PT SESSION BY LICENSED PT 8 8.250000 517.9400 62.7806
SENS-V5264-EARMOLD 1 2.000000 36.0000 18.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 115 673.500000 46971.8000 69.7428
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 13 13.500000 964.4400 71.4400
Subtotal (Total Children Is Unduplicated) 246 1678.000000 101601.1400 60.5490
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Total 2267.250000 138998.8800 61.3073
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Number of Children (Unduplicated) With at Least One Service 305
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Center 52
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 2.000000 100.0000 0.0000
P 36 50.000000 3525.5000 2528.9800
D 4 4.000000 200.0000 200.0000
S 4 6.000000 311.0000 122.5000
H 122 170.000000 11501.9800 0.0000
T 942 1503.750000 92914.8100 86252.9800
347 531.500000 30445.5900 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 1457 2267.250000 138998.8800 89104.4600