CMS/EIP Fiscal Report Center: 01
Services beginning 04/01/2020 ending 06/30/2020 Date of Report:07/21/2020 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 1536 6082.000000 225034.0000 37.0000
Subtotal (Total Children Is Unduplicated) 1536 6082.000000 225034.0000 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 3 4.500000 337.5000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 1 1.500000 112.5000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 3 5.000000 375.0000 75.0000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 3 5.000000 277.5000 55.5000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 16 26.500000 1987.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 5 11.500000 862.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 3 5.000000 375.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 4 7.000000 388.5000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 93 150.500000 8352.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 8 12.000000 900.0000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 130 289.500000 21712.5000 75.0000
OCTH-97167TLGT-OT EVAL HIGH COMPLEXITY 1 1.000000 51.0500 51.0500
PSTH-97163GT-PT EVAL HIGH COMPLEXITY 1 1.000000 51.0500 51.0500
SPCH-92523TLGT-EVAL OF SPCH SOUND PROD; EVAL LANG COM 1 1.000000 51.0500 51.0500
Subtotal (Total Children Is Unduplicated) 162 521.000000 35834.4000 68.7800
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 18 40.750000 2037.5000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 87 393.750000 19687.5000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 1 1.000000 71.4400 71.4400
OCCT-97530GT-OT SESSION BY LICENSED OT 30 189.750000 13555.7400 71.4400
OCCT-97530TLGT-OT SESSION BY LICENSED OT 1 1.750000 125.0200 71.4400
PHY-97110-PT SESSION BY LICENSED PT 2 2.000000 142.8800 71.4400
PHY-97110GT-PT SESSION BY LICENSED PT 21 120.000000 8572.8000 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 1 1.000000 71.4400 71.4400
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 20 87.000000 6215.2800 71.4400
Subtotal (Total Children Is Unduplicated) 159 837.000000 50479.6000 60.3102
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Total 7440.000000 311348.0000 41.8478
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Number of Children (Unduplicated) With at Least One Service 1541
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Center 01
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 1 0.750000 27.7500 0.0000
P 0 0.000000 0.0000 0.0000
D 100 99.000000 5116.7800 0.0000
S 4212 2761.750000 112808.1600 0.0000
H 6686 4464.000000 185874.3100 185874.3100
T 0 0.000000 0.0000 0.0000
22 18.000000 701.7500 0.0000
Other 57 96.500000 6819.2500 0.0000
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Total 11078 7440.000000 311348.0000 185874.3100