CMS/EIP Fiscal Report Center: 55
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: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 869 2865.250000 105958.7500 36.9806
Subtotal (Total Children Is Unduplicated) 869 2865.250000 105958.7500 36.9806
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 7 14.000000 1050.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 3 6.000000 450.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 3 6.000000 450.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 2 4.000000 222.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 91 184.000000 13800.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 71 142.000000 10650.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 23 46.000000 3450.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 27 54.000000 2997.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 4 8.000000 600.0000 75.0000
OCTF-97168-OT RE-EVAL EST PLAN CARE 6 6.000000 306.3000 51.0500
OCTH-97166-OT EVAL MODERATE COMPLEXITY 1 1.000000 51.0500 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 22 22.000000 1123.1000 51.0500
PSTF-97164-PT RE-EVAL EST PLAN CARE 1 1.000000 51.0500 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 3 3.000000 153.1500 51.0500
SPCH-92522-EVAL OF SPCH SOUND PROD 1 1.000000 51.0500 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 15 16.000000 816.8000 51.0500
SPCH-92524-BEHAV & QUAL ANALYSIS OF VOICE AND RES 1 1.000000 51.0500 51.0500
SPCH-92610-EVAL OF ORAL,PHARYNGEAL SWALLOWING FUNC 1 1.000000 48.9400 48.9400
Subtotal (Total Children Is Unduplicated) 170 516.000000 36321.4900 70.3905
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EI Services,Class #03
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 4 12.750000 318.7500 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 381 2620.250000 131012.5000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 20 19.250000 962.5000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 78 512.500000 36613.0000 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 103 603.000000 34491.6000 57.2000
OCCT-97530HMGT-OT SESSION BY OT ASST 3 5.000000 286.0000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 29 202.750000 14484.4600 71.4400
PHY-97110GT-PT SESSION BY LICENSED PT 1 1.000000 71.4400 71.4400
PHY-97110HM-PT SESSION BY PT ASST 34 205.000000 11717.8000 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 140 799.660134 57127.7200 71.4400
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 6 7.000000 485.8000 69.4000
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 1 9.000000 642.9600 71.4400
SPL-92508-GROUP SPL SESSION PER CHILD 1 3.000000 41.6400 13.8800
Subtotal (Total Children Is Unduplicated) 599 5000.160134 288256.1700 57.6494
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Total 8381.410134 430536.4100 51.3680
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Number of Children (Unduplicated) With at Least One Service 903
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Center 55
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 1096 852.250000 34522.7800 129.5000
P 3345 2423.000000 96158.4900 112554.7900
D 0 0.000000 0.0000 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
5030 5103.160134 299661.2100 0.0000
Other 3 3.000000 193.9300 0.0000
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Total 9474 8381.410134 430536.4100 112684.2900