CMS/EIP Fiscal Report Center: 09
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 1143 4324.000000 159960.2500 36.9936
Subtotal (Total Children Is Unduplicated) 1143 4324.000000 159960.2500 36.9936
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 7 13.500000 1012.5000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 4 7.500000 562.5000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 4 8.000000 600.0000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 1 1.500000 112.5000 75.0000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 6 11.500000 638.2500 55.5000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 92 171.000000 12825.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 52 100.000000 7500.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 84 160.500000 12037.5000 75.0000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 143 273.500000 15129.2500 55.3172
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 8 14.500000 1087.5000 75.0000
Subtotal (Total Children Is Unduplicated) 202 761.500000 51505.0000 67.6362
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 311 1794.000000 89700.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 354 2178.000000 108900.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 31 153.000000 10930.3200 71.4400
OCCT-97530GT-OT SESSION BY LICENSED OT 19 99.000000 7072.5600 71.4400
PHY-97110-PT SESSION BY LICENSED PT 41 179.000000 12787.7600 71.4400
PHY-97110GT-PT SESSION BY LICENSED PT 21 135.000000 9644.4000 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 87 432.000000 30862.0800 71.4400
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 47 304.250000 21735.6200 71.4400
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 2 5.000000 357.2000 71.4400
Subtotal (Total Children Is Unduplicated) 659 5279.250000 291989.9400 55.3090
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Total 10364.750000 503455.1900 48.5738
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Number of Children (Unduplicated) With at Least One Service 1221
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Center 09
Flag Claims Units Chgs Paid
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R 40 51.500000 2183.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 626 701.250000 27478.0000 0.0000
P 3914 4082.750000 162166.2500 162166.2500
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 3 13.000000 481.0000 425.5000
1586 5198.250000 287939.9400 0.0000
Other 163 318.000000 23206.5000 0.0000
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Total 6332 10364.750000 503455.1900 162591.7500