CMS/EIP Fiscal Report Center: 04
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 1251 5576.250000 206306.2500 36.9973
Subtotal (Total Children Is Unduplicated) 1251 5576.250000 206306.2500 36.9973
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 9 9.000000 675.0000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 16 17.000000 1275.0000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 15 24.000000 1800.0000 75.0000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 25 33.000000 1831.5000 55.5000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 24 25.000000 1875.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 39 41.000000 3075.0000 75.0000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 87 113.000000 6271.5000 55.5000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 37 43.500000 3262.5000 75.0000
OCTH-97165TLGT-OT EVAL LOW COMPLEXITY 1 3.000000 153.1500 51.0500
OCTH-97166-OT EVAL MODERATE COMPLEXITY 2 2.000000 102.1000 51.0500
OCTH-97166GT-OT EVAL MODERATE COMPLEXITY 1 1.000000 51.0500 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 8 8.000000 408.4000 51.0500
OCTH-97167GT-OT EVAL HIGH COMPLEXITY 6 6.000000 306.3000 51.0500
PSTH-97162GT-PT EVAL MODERATE COMPLEXITY 5 5.000000 255.2500 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 6 7.000000 357.3500 51.0500
PSTH-97163GT-PT EVAL HIGH COMPLEXITY 8 8.000000 408.4000 51.0500
Subtotal (Total Children Is Unduplicated) 155 345.500000 22107.5000 63.9870
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 408 2918.000000 145850.0000 49.9829
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 336 2460.750000 123037.5000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 11 46.500000 3321.9600 71.4400
OCCT-97530GT-OT SESSION BY LICENSED OT 9 45.000000 3214.8000 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 15 55.000000 3146.0000 57.2000
OCCT-97530HMGT-OT SESSION BY OT ASST 15 77.000000 4404.4000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 17 72.500000 5179.4000 71.4400
PHY-97110GT-PT SESSION BY LICENSED PT 6 20.000000 1428.8000 71.4400
PHY-97110HM-PT SESSION BY PT ASST 18 144.000000 8231.0400 57.1600
PHY-97110HMGT-PT SESSION BY LICENSED PT ASST 6 11.000000 628.7600 57.1600
PHY-97110TLGT-PT SESSION BY LICENSED PT 1 14.000000 1000.1600 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 5 23.000000 1643.1200 71.4400
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 1 1.000000 71.4400 71.4400
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 1 0.500000 35.7200 71.4400
Subtotal (Total Children Is Unduplicated) 703 5888.250000 301193.1000 51.1515
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Total 11810.000000 529606.8500 44.8439
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Number of Children (Unduplicated) With at Least One Service 1363
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Center 04
Flag Claims Units Chgs Paid
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R 444 582.750000 21561.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 2971 4297.750000 159001.7500 0.0000
P 548 739.250000 28906.9500 25635.1700
D 0 0.000000 0.0000 0.0000
S 1 2.000000 74.0000 0.0000
H 1700 5872.250000 299470.3000 0.0000
T 0 0.000000 0.0000 0.0000
271 308.000000 20158.0000 0.0000
Other 3 8.000000 434.1000 200.0000
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Total 5938 11810.000000 529606.8500 25835.1700