CMS/EIP Fiscal Report Center: 54
Services beginning 04/01/2020 ending 06/30/2020 Date of Report:07/20/2020 Page: 1
List order: No List
Payclass Filters:MED
Bill Flag Filter:RBPU
Eligibility Filter:All
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 881 2550.250000 94176.2500 36.9282
Subtotal (Total Children Is Unduplicated) 881 2550.250000 94176.2500 36.9282
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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 3 5.500000 412.5000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 3 5.000000 375.0000 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 6 10.000000 750.0000 75.0000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 1 1.500000 83.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 7 14.000000 1050.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 28 46.000000 3450.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 33 52.000000 3900.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 15 25.000000 1875.0000 75.0000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 6 9.500000 527.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 3 4.000000 300.0000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 38 68.500000 5137.5000 75.0000
SCREEN-T1023-SCREENING 7 7.000000 350.0000 50.0000
Subtotal (Total Children Is Unduplicated) 111 254.000000 18660.5000 73.4665
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 3 3.000000 150.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 46 152.000000 7600.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 2 2.000000 142.8800 71.4400
OCCT-97530GT-OT SESSION BY LICENSED OT 21 33.750000 2411.1000 71.4400
OCCT-97530TL-OT SESSION BY LICENSED OT 1 1.000000 71.4400 71.4400
OCCT-97530TLGT-OT SESSION BY LICENSED OT 46 140.500000 10037.3200 71.4400
PHY-97110GT-PT SESSION BY LICENSED PT 12 16.000000 1143.0400 71.4400
PHY-97110TL-PT SESSION BY LICENSED PT 2 2.000000 142.8800 71.4400
PHY-97110TLGT-PT SESSION BY LICENSED PT 34 91.750000 6554.6200 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 1 0.250000 17.8600 71.4400
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 24 36.000000 2571.8400 71.4400
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 5 5.000000 357.2000 71.4400
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 31 91.500000 6536.7600 71.4400
SPL-92508TLGT-SPL THERAPY SESSION BY LICENSED SLP 2 3.000000 41.6400 13.8800
Subtotal (Total Children Is Unduplicated) 170 577.750000 37778.5800 65.3891
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Total 3382.000000 150615.3300 44.5344
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Number of Children (Unduplicated) With at Least One Service 902
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Center 54
Flag Claims Units Chgs Paid
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R 7 4.500000 261.2100 0.0000
U 0 0.000000 0.0000 0.0000
B 2461 2054.750000 92940.9600 9.2500
P 1608 1322.750000 57413.1600 57276.0900
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
0 0.000000 0.0000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 4076 3382.000000 150615.3300 57285.3400