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
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 1176 4112.000000 151922.0000 36.9460
Subtotal (Total Children Is Unduplicated) 1176 4112.000000 151922.0000 36.9460
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 11 18.500000 1387.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 9 11.000000 825.0000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 1 1.000000 75.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 5 9.000000 675.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 7 12.000000 900.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 22 33.500000 1859.2500 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 2 2.500000 138.7500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 94 154.500000 11587.5000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 5 7.500000 562.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 65 91.000000 6787.5000 74.5879
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 16 22.500000 1687.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 45 69.000000 5175.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 154 238.000000 13209.0000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 14 22.000000 1221.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 65 110.500000 8250.0000 74.6606
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 7 10.000000 750.0000 75.0000
SCREEN-T1023-SCREENING 7 7.000000 350.0000 50.0000
Subtotal (Total Children Is Unduplicated) 280 819.500000 55440.5000 67.6516
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 550 3428.000000 171362.5000 49.9891
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 74 100.750000 5037.5000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 65 302.250000 21592.7400 71.4400
OCCT-97530GT-OT SESSION BY LICENSED OT 20 24.750000 1768.1400 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 1 1.000000 57.2000 57.2000
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 55 183.750000 13127.1000 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 46 203.000000 14502.3200 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 2 2.000000 27.7600 13.8800
Subtotal (Total Children Is Unduplicated) 713 4286.250000 230357.9600 53.7435
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Total 9217.750000 437720.4600 47.4867
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Number of Children (Unduplicated) With at Least One Service 1203
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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 1417 1200.750000 56538.5500 157.2500
P 5343 4234.000000 185384.9700 191275.7500
D 213 186.000000 11400.3400 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
3443 3529.250000 180309.8300 0.0000
Other 67 64.500000 3960.0200 0.0000
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Total 10487 9217.750000 437720.4600 191470.5500