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:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 952 3237.500000 119732.0000 36.9829
Subtotal (Total Children Is Unduplicated) 952 3237.500000 119732.0000 36.9829
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 13 26.000000 1950.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 7 14.000000 1050.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 6 12.000000 900.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 4 8.000000 444.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 144 290.000000 21750.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 111 222.000000 16650.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 38 75.000000 5625.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 49 98.000000 5439.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 5 10.000000 750.0000 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) 249 807.000000 57210.4900 70.8928
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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 9044.660134 465198.6600 51.4335
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Number of Children (Unduplicated) With at Least One Service 986
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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 1181 974.000000 40243.5300 129.5000
P 3646 2777.500000 112010.9900 128246.2900
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
5124 5290.160134 312750.2100 0.0000
Other 3 3.000000 193.9300 0.0000
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Total 9954 9044.660134 465198.6600 128375.7900