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:OTHER
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 106 145.000000 5346.5000 36.8724
Subtotal (Total Children Is Unduplicated) 106 145.000000 5346.5000 36.8724
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 4 6.000000 450.0000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 2 3.000000 225.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 3 4.500000 337.5000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 6 9.000000 499.5000 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 3 4.500000 249.7500 55.5000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 59 83.000000 6187.5000 74.5482
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 47 65.500000 4912.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 20 39.500000 2962.5000 75.0000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 96 130.000000 7159.5000 55.0731
Subtotal (Total Children Is Unduplicated) 132 347.000000 23133.7500 66.6679
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 12 15.000000 750.0000 50.0000
COIFF-COIFFGT-IFSP CONSULT,PROF,FACE TO FACE 8 13.500000 675.0000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 17 21.500000 537.5000 25.0000
CONIF-CONIFGT-CONSULT,ITDS,FACE TO FACE 4 4.000000 200.0000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 1 1.000000 50.0000 50.0000
CONSF-CONSFGT-CONSULT,SLP,FACE TO FACE 3 3.000000 150.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 50 207.000000 10350.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 100 443.000000 22150.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 5 29.000000 2071.7600 71.4400
OCCT-97530GT-OT SESSION BY LICENSED OT 8 32.000000 2286.0800 71.4400
PHY-97110-PT SESSION BY LICENSED PT 18 57.000000 4072.0800 71.4400
PHY-97110GT-PT SESSION BY LICENSED PT 9 40.000000 2857.6000 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 52 228.000000 16288.3200 71.4400
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 52 232.000000 16574.0800 71.4400
TRAV-TRAVS-Travel by mile 104 5158.000000 2248.7800 0.4360
Subtotal (Total Children Is Unduplicated) 323 6484.000000 81261.2000 12.5326
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Total 6976.000000 109741.4500 15.7313
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Number of Children (Unduplicated) With at Least One Service 451
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Center 09
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 0 0.000000 0.0000 0.0000
P 448 5213.500000 68936.2000 68936.2000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 318 434.500000 24167.7500 0.0000
T 0 0.000000 0.0000 0.0000
113 1328.000000 16637.5000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 879 6976.000000 109741.4500 68936.2000