CMS/EIP Fiscal Report Center: 54
Services beginning 01/01/2020 ending 03/31/2020 Date of Report:05/15/2020 Page: 1
List order: No List
Agency Filter:EIP DEI DEIP
Payclass Filters:MED
Eligibility Filter:Part C (excluding not eligible)
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 1069 3549.000000 131100.2500 36.9401
Subtotal (Total Children Is Unduplicated) 1069 3549.000000 131100.2500 36.9401
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 9 16.000000 1200.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 7 8.500000 637.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 3 5.500000 412.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 3 5.500000 412.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 4 7.000000 388.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 65 110.000000 8250.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 3 4.500000 337.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 34 51.000000 3787.5000 74.2647
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 9 13.500000 1012.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 29 46.500000 3487.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 30 49.000000 2719.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 31 54.000000 4050.0000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 2 3.500000 262.5000 75.0000
SCREEN-T1023-SCREENING 7 7.000000 350.0000 50.0000
Subtotal (Total Children Is Unduplicated) 177 381.500000 27308.0000 71.5806
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 74 322.500000 16125.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 15 21.500000 1075.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 55 273.250000 19520.9800 71.4400
OCCT-97530GT-OT SESSION BY LICENSED OT 18 23.000000 1643.1200 71.4400
OCCT-97530HMGT-OT SESSION BY OT ASST 1 1.000000 57.2000 57.2000
OCCT-97530TL-OT SESSION BY LICENSED OT 3 3.000000 214.3200 71.4400
OCCT-97530TLGT-OT SESSION BY LICENSED OT 1 1.000000 71.4400 71.4400
PHY-97110-PT SESSION BY LICENSED PT 45 147.750000 10555.2600 71.4400
PHY-97110GT-PT SESSION BY LICENSED PT 11 14.000000 1000.1600 71.4400
PHY-97110TLGT-PT SESSION BY LICENSED PT 1 1.000000 71.4400 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 45 201.000000 14359.4400 71.4400
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 14 17.750000 1268.0600 71.4400
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 1 1.000000 57.2000 57.2000
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 2 2.000000 142.8800 71.4400
SPL-92508-GROUP SPL SESSION PER CHILD 1 1.000000 13.8800 13.8800
Subtotal (Total Children Is Unduplicated) 228 1030.750000 66175.3800 64.2012
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Total 4961.250000 224583.6300 45.2675
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Number of Children (Unduplicated) With at Least One Service 1074
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Center 54
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 1251 1032.500000 48556.5500 157.2500
P 4806 3682.750000 160958.7200 167047.0000
D 199 172.750000 10739.0900 3.3000
S 0 0.000000 0.0000 0.0000
H 4 3.250000 126.7500 34.2500
T 0 0.000000 0.0000 0.0000
9 7.250000 307.2500 0.0000
Other 64 62.750000 3895.2700 0.0000
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Total 6333 4961.250000 224583.6300 167241.8000