CMS/EIP Fiscal Report Center: 54
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 1001 3635.500000 134256.5000 36.9293
Subtotal (Total Children Is Unduplicated) 1001 3635.500000 134256.5000 36.9293
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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 8 13.500000 1012.5000 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 3 5.000000 375.0000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 7 11.500000 837.5000 72.8261
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 1.500000 83.2500 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 10 18.500000 1026.7500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 5 10.000000 750.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 53 94.000000 7012.5000 74.6011
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 40 65.000000 4875.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 23 39.500000 2962.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 2 2.500000 138.7500 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 87 153.500000 8519.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 4 6.000000 450.0000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 55 105.500000 7912.5000 75.0000
SCREEN-T1023-SCREENING 10 10.000000 500.0000 50.0000
Subtotal (Total Children Is Unduplicated) 151 545.000000 37130.5000 68.1294
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 89 194.750000 9737.5000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 401 2409.500000 120475.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 2 2.000000 142.8800 71.4400
OCCT-97530GT-OT SESSION BY LICENSED OT 25 48.000000 3429.1200 71.4400
OCCT-97530TL-OT SESSION BY LICENSED OT 1 1.000000 71.4400 71.4400
OCCT-97530TLGT-OT SESSION BY LICENSED OT 53 235.500000 16824.1200 71.4400
PHY-97110-PT SESSION BY LICENSED PT 3 3.000000 214.3200 71.4400
PHY-97110GT-PT SESSION BY LICENSED PT 18 44.000000 3143.3600 71.4400
PHY-97110TL-PT SESSION BY LICENSED PT 2 2.000000 142.8800 71.4400
PHY-97110TLGT-PT SESSION BY LICENSED PT 39 145.750000 10412.3800 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 36.750000 2625.4200 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 46 173.250000 12376.9800 71.4400
SPL-92508TLGT-SPL THERAPY SESSION BY LICENSED SLP 5 7.000000 97.1600 13.8800
Subtotal (Total Children Is Unduplicated) 567 3307.750000 180067.6200 54.4381
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Total 7488.250000 351454.6200 46.9341
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Number of Children (Unduplicated) With at Least One Service 1020
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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 2347 1928.250000 87149.7100 9.2500
P 1537 1245.000000 53956.1600 53819.0900
D 56 35.000000 1320.8300 9.2500
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
4463 4274.500000 208729.7100 0.0000
Other 1 1.000000 37.0000 0.0000
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Total 8411 7488.250000 351454.6200 53837.5900