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:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 1596 6450.250000 238659.2500 37.0000
Subtotal (Total Children Is Unduplicated) 1596 6450.250000 238659.2500 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 4 6.500000 487.5000 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 4 7.000000 388.5000 55.5000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 22 34.500000 2587.5000 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 6 9.500000 712.5000 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 122 192.000000 10656.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 10 14.500000 1087.5000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 172 374.000000 28050.0000 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) 213 666.000000 45861.1500 68.8606
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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 7953.250000 335000.0000 42.1211
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Number of Children (Unduplicated) With at Least One Service 1601
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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 4381 2918.000000 119552.9100 0.0000
H 7023 4790.500000 200601.3100 200601.3100
T 0 0.000000 0.0000 0.0000
22 18.000000 701.7500 0.0000
Other 77 127.000000 8999.5000 0.0000
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Total 11604 7953.250000 335000.0000 200601.3100