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:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 442 1558.250000 57609.0000 36.9703
Subtotal (Total Children Is Unduplicated) 442 1558.250000 57609.0000 36.9703
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 3 6.000000 450.0000 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 2 6.000000 333.0000 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 36 73.000000 5436.0000 74.4658
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 15 30.000000 2250.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 25 49.500000 3712.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 7 11.500000 862.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 11 21.500000 1612.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 15 29.500000 1637.2500 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 43 84.500000 4679.9000 55.3834
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) 110 391.500000 26136.7000 66.7604
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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 3240.250000 160766.7000 49.6155
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Number of Children (Unduplicated) With at Least One Service 489
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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 1373 1417.500000 63314.7000 0.0000
P 277 250.250000 9505.4400 9560.9400
D 0 0.000000 0.0000 0.0000
S 324 355.500000 13832.2400 46.7500
H 0 0.000000 0.0000 0.0000
T 1 1.000000 37.0000 0.0000
657 1210.000000 73627.3200 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 2635 3240.250000 160766.7000 9607.6900