CMS/EIP Fiscal Report Center: 57
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 1104 4545.250000 168174.2500 37.0000
Subtotal (Total Children Is Unduplicated) 1104 4545.250000 168174.2500 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 7 9.000000 675.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 1.500000 112.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 8 10.000000 555.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 126 138.500000 10387.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 20 37.000000 2775.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 60 68.500000 5137.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 198 254.000000 14097.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 6 8.500000 637.5000 75.0000
OCTH-97167-OT EVAL HIGH COMPLEXITY 12 12.000000 612.6000 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 2 2.000000 102.1000 51.0500
Subtotal (Total Children Is Unduplicated) 219 541.000000 35091.7000 64.8645
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 833 6383.500000 319175.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 71 84.000000 4200.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 6 40.000000 2857.6000 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 1 3.000000 171.6000 57.2000
OCCT-97530TLGT-OT SESSION BY LICENSED OT 1 1.000000 71.4400 71.4400
PHY-97110-PT SESSION BY LICENSED PT 1 11.000000 785.8400 71.4400
PHY-97110HM-PT SESSION BY PT ASST 3 27.000000 1543.3200 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 2 2.500000 178.6000 71.4400
Subtotal (Total Children Is Unduplicated) 838 6552.000000 328983.4000 50.2111
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Total 11638.250000 532249.3500 45.7328
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Number of Children (Unduplicated) With at Least One Service 1168
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Center 57
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 355 366.000000 15413.5000 18.5000
P 4464 4628.000000 182377.0000 180150.6720
D 13 6.500000 240.5000 0.0000
S 1 3.000000 111.0000 111.0000
H 4 4.750000 213.7500 75.0000
T 0 0.000000 0.0000 0.0000
2194 6630.000000 333893.6000 333943.6000
Other 0 0.000000 0.0000 0.0000
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Total 7031 11638.250000 532249.3500 514298.7720