CMS/EIP Fiscal Report Center: 51
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 281 660.750000 24447.7500 37.0000
Subtotal (Total Children Is Unduplicated) 281 660.750000 24447.7500 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 1 1.000000 75.0000 75.0000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 2 2.000000 111.0000 55.5000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 26 27.500000 2033.2500 73.9364
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 8 8.000000 600.0000 75.0000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 40 42.500000 2358.7500 55.5000
SPCH-92521GT-EVAL OF SPEECH FLUENCY 1 1.000000 51.0500 51.0500
Subtotal (Total Children Is Unduplicated) 43 82.000000 5229.0500 63.7689
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 20 42.000000 2100.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 23 70.500000 3525.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 11 40.000000 2857.6000 71.4400
OCCT-97530GT-OT SESSION BY LICENSED OT 1 1.000000 71.4400 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 1 1.000000 57.2000 57.2000
OCCT-97530HMGT-OT SESSION BY OT ASST 2 9.000000 514.8000 57.2000
OCCT-97530TLGT-OT SESSION BY LICENSED OT 1 1.000000 71.4400 71.4400
PHY-97110-PT SESSION BY LICENSED PT 2 6.750000 482.2200 71.4400
PHY-97110GT-PT SESSION BY LICENSED PT 4 15.000000 779.1500 51.9433
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 19 60.500000 4322.1200 71.4400
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 37 99.250000 7090.4200 71.4400
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 7 13.000000 928.7200 71.4400
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 11 28.750000 2053.9000 71.4400
SPL-92508TLGT-SPL THERAPY SESSION BY LICENSED SLP 1 1.000000 13.8800 13.8800
Subtotal (Total Children Is Unduplicated) 112 388.750000 24867.8900 63.9688
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Total 1131.500000 54544.6900 48.2056
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Number of Children (Unduplicated) With at Least One Service 337
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Center 51
Flag Claims Units Chgs Paid
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R 15 8.000000 296.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 932 719.250000 28839.1700 0.0000
P 3 2.500000 99.0000 74.0000
D 15 13.000000 481.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
165 388.750000 24829.5200 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 1130 1131.500000 54544.6900 74.0000