CMS/EIP Fiscal Report Center: 52
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:Part C (excluding not eligible)
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 431 1506.500000 55694.2500 36.9693
Subtotal (Total Children Is Unduplicated) 431 1506.500000 55694.2500 36.9693
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 2 4.000000 300.0000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 2 4.000000 300.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 2 3.000000 225.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 4.000000 222.0000 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 3 6.000000 333.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 13 26.000000 1950.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 32 65.500000 4873.5000 74.4046
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 14 28.000000 2100.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 24 47.500000 3562.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 4 7.000000 525.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 9 18.000000 1350.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 13 26.000000 1443.0000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 40 78.500000 4346.9000 55.3745
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 2.000000 150.0000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 3 6.000000 450.0000 75.0000
OCTH-97166TL-OT EVAL MODERATE COMPLEXITY 1 1.000000 51.0500 51.0500
OCTH-97166TLGT-OT EVAL MODERATE COMPLEXITY 1 1.000000 51.0500 51.0500
SCREEN-T1023-SCREENING 18 18.000000 900.0000 50.0000
SPCH-92523TL-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 5 5.000000 255.2500 51.0500
SPCH-92523TLGT-EVAL OF SPCH SOUND PROD; EVAL LANG COM 3 3.000000 153.1500 51.0500
SPCH-92610TLGT-EVAL OF ORAL,PHARYNGEAL SWALLOWING FUN 1 1.000000 44.5500 44.5500
Subtotal (Total Children Is Unduplicated) 100 358.500000 23885.9500 66.6275
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 109 298.500000 14925.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 115 383.250000 19162.5000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 1 2.000000 142.8800 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 1 2.000000 114.4000 57.2000
OCCT-97530TL-OT SESSION BY LICENSED OT 21 41.750000 2911.1800 69.7289
OCCT-97530TLGT-OT SESSION BY LICENSED OT 27 100.250000 7161.8600 71.4400
OCCT-97530TLGTHM-OT SESSION BY OT ASST 8 28.000000 1601.6000 57.2000
OCCT-97530TLHM-OT SESSION BY OT ASST 3 4.000000 228.8000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 1 2.000000 142.8800 71.4400
PHY-97110TL-PT SESSION BY LICENSED PT 25 61.500000 4393.5600 71.4400
PHY-97110TLGT-PT SESSION BY LICENSED PT 19 75.250000 5375.8600 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 3 3.000000 214.3200 71.4400
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 41 112.250000 8019.1400 71.4400
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 43 176.750000 12627.0200 71.4400
Subtotal (Total Children Is Unduplicated) 265 1290.500000 77021.0000 59.6831
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Total 3155.500000 156601.2000 49.6280
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Number of Children (Unduplicated) With at Least One Service 477
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Center 52
Flag Claims Units Chgs Paid
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R 3 6.000000 450.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 1333 1360.500000 60598.7000 0.0000
P 270 242.000000 9200.1900 9255.6900
D 0 0.000000 0.0000 0.0000
S 321 352.000000 13702.7400 46.7500
H 0 0.000000 0.0000 0.0000
T 1 1.000000 37.0000 0.0000
648 1194.000000 72612.5700 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 2576 3155.500000 156601.2000 9302.4400