CMS/EIP Fiscal Report Center: 10
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 2182 6720.750000 248667.7500 37.0000
Subtotal (Total Children Is Unduplicated) 2182 6720.750000 248667.7500 37.0000
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 1.500000 112.5000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 4 8.000000 600.0000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 2 4.000000 300.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 1.500000 83.2500 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 1 2.000000 111.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 22 42.500000 3187.5000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 195 347.500000 26023.5000 74.8878
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 4 7.000000 525.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 66 108.500000 8137.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 7 12.000000 900.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 80 138.500000 10348.5000 74.7184
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 25 47.000000 2608.5000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 168 298.000000 16539.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 4 8.000000 600.0000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 70 109.500000 8212.5000 75.0000
OCTH-97167-OT EVAL HIGH COMPLEXITY 1 1.000000 51.0500 51.0500
OCTH-97167GT-OT EVAL HIGH COMPLEXITY 1 1.000000 51.0500 51.0500
PSTH-97162-PT EVAL MODERATE COMPLEXITY 1 1.000000 51.0500 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 1 1.000000 51.0500 51.0500
PSTH-97163GT-PT EVAL HIGH COMPLEXITY 1 1.000000 51.0500 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 2 2.000000 102.1000 51.0500
SPCH-92523GT-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 1 1.000000 51.0500 51.0500
SPCH-92524GT-BEHAV & QUAL ANALYSIS OF VOICE AND RES 5 5.000000 255.2500 51.0500
Subtotal (Total Children Is Unduplicated) 310 1150.500000 79102.4000 68.7548
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 1 3.000000 639.5400 213.1800
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 255 1354.750000 67737.5000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 667 5622.750000 281137.5000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 53 189.000000 13502.1600 71.4400
OCCT-97530GT-OT SESSION BY LICENSED OT 66 317.000000 22646.4800 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 8 52.500000 3003.0000 57.2000
OCCT-97530HMGT-OT SESSION BY OT ASST 4 24.500000 1401.4000 57.2000
OCCT-97530TLGT-OT SESSION BY LICENSED OT 1 0.750000 53.5800 71.4400
PHY-97110-PT SESSION BY LICENSED PT 107 373.750000 26700.7000 71.4400
PHY-97110GT-PT SESSION BY LICENSED PT 99 326.000000 23211.0700 71.1996
PHY-97110HM-PT SESSION BY PT ASST 1 2.500000 142.9000 57.1600
PHY-97110TLGT-PT SESSION BY LICENSED PT 4 6.000000 428.6400 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 66 248.500000 17752.8400 71.4400
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 139 686.750000 49061.4200 71.4400
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 4 10.500000 750.1200 71.4400
Subtotal (Total Children Is Unduplicated) 1069 9218.250000 508168.8500 55.1264
-----------------------------------------------------------------------------------------------------------------------
Total 17089.500000 835939.0000 48.9154
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 2277
-----------------------------------------------------------------------------------------------------------------------
Center 10
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 491 376.000000 14234.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 2750 2030.750000 82615.5000 0.0000
P 7231 5171.500000 212538.8900 211526.4250
D 85 54.250000 2157.2500 0.0000
S 138 259.000000 17374.7500 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
2856 9196.250000 506953.8600 0.0000
Other 2 1.750000 64.7500 0.0000
---------------------------------------------------------
Total 13553 17089.500000 835939.0000 211526.4250