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:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 1265 5676.750000 210024.7500 36.9974
Subtotal (Total Children Is Unduplicated) 1265 5676.750000 210024.7500 36.9974
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 10 10.000000 750.0000 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 26 34.500000 1914.7500 55.5000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 25 26.000000 1950.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 42 45.000000 3375.0000 75.0000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 92 119.000000 6604.5000 55.5000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 39 45.000000 3375.0000 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) 161 360.500000 23086.2500 64.0395
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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 16 79.000000 4518.8000 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) 704 5890.250000 301307.5000 51.1536
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Total 11927.500000 534418.5000 44.8056
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Number of Children (Unduplicated) With at Least One Service 1377
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Center 04
Flag Claims Units Chgs Paid
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R 450 592.500000 21922.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 3026 4382.250000 162128.2500 0.0000
P 552 745.500000 29138.2000 25866.4200
D 0 0.000000 0.0000 0.0000
S 1 2.000000 74.0000 0.0000
H 1701 5874.250000 299584.7000 0.0000
T 0 0.000000 0.0000 0.0000
284 323.000000 21136.7500 0.0000
Other 3 8.000000 434.1000 200.0000
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Total 6017 11927.500000 534418.5000 26066.4200