CMS/EIP Fiscal Report Center: 03
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 711 2144.000000 79328.0000 37.0000
Subtotal (Total Children Is Unduplicated) 711 2144.000000 79328.0000 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 2 4.000000 300.0000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 1 2.000000 111.0000 55.5000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 37 59.500000 4462.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 13 24.500000 1837.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 7 10.000000 750.0000 75.0000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 21 33.000000 1831.5000 55.5000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 4 7.500000 562.5000 75.0000
OCTH-97166GT-OT EVAL MODERATE COMPLEXITY 1 1.000000 51.0500 51.0500
SCREEN-T1023-SCREENING 2 2.000000 100.0000 50.0000
SPCH-92523TLGT-EVAL OF SPCH SOUND PROD; EVAL LANG COM 2 2.000000 102.1000 51.0500
Subtotal (Total Children Is Unduplicated) 48 147.500000 10258.1500 69.5468
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EI Services,Class #03
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 11 37.750000 1887.5000 50.0000
OCCT-97530GT-OT SESSION BY LICENSED OT 1 1.000000 71.4400 71.4400
OCCT-97530TLGT-OT SESSION BY LICENSED OT 2 4.000000 285.7600 71.4400
PHY-97110-PT SESSION BY LICENSED PT 1 1.000000 71.4400 71.4400
PHY-97110GT-PT SESSION BY LICENSED PT 4 5.250000 375.0600 71.4400
PHY-97110TLGT-PT SESSION BY LICENSED PT 1 2.000000 142.8800 71.4400
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 4 8.750000 625.1000 71.4400
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 6 7.750000 553.6600 71.4400
Subtotal (Total Children Is Unduplicated) 28 67.500000 4012.8400 59.4495
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Total 2359.000000 93598.9900 39.6774
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Number of Children (Unduplicated) With at Least One Service 720
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Center 03
Flag Claims Units Chgs Paid
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R 179 147.500000 5954.9600 0.0000
U 0 0.000000 0.0000 0.0000
B 3213 2142.250000 83145.2500 0.0000
P 0 0.000000 0.0000 0.0000
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
67 69.250000 4498.7800 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 3459 2359.000000 93598.9900 0.0000