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:TPIN
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 1 1.500000 55.5000 37.0000
Subtotal (Total Children Is Unduplicated) 1 1.500000 55.5000 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 1 1.000000 75.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 2 2.000000 150.0000 75.0000
SPCH-92524GT-BEHAV & QUAL ANALYSIS OF VOICE AND RES 1 1.000000 51.0500 51.0500
Subtotal (Total Children Is Unduplicated) 4 4.000000 276.0500 69.0125
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1 4.000000 200.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 1 4.000000 200.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 7 16.000000 1143.0400 71.4400
OCCT-97530GT-OT SESSION BY LICENSED OT 2 3.000000 214.3200 71.4400
PHY-97110GT-PT SESSION BY LICENSED PT 2 7.000000 500.0800 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 13 42.250000 2953.1500 69.8970
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 38 128.750000 9090.7400 70.6077
Subtotal (Total Children Is Unduplicated) 59 205.000000 14301.3300 69.7626
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Total 210.500000 14632.8800 69.5149
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Number of Children (Unduplicated) With at Least One Service 63
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Center 51
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 60 183.000000 12716.3800 12716.3800
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 0 0.000000 0.0000 0.0000
9 27.500000 1916.5000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 69 210.500000 14632.8800 12716.3800