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
Agency Filter:EIP DEI DEIP
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 6 10.500000 787.5000 75.0000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 1 2.000000 111.0000 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 38 63.000000 4725.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 20 34.500000 2587.5000 75.0000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 11 20.500000 1137.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 2 2.500000 187.5000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 53 102.000000 7650.0000 75.0000
SCREEN-T1023-SCREENING 10 10.000000 500.0000 50.0000
Subtotal (Total Children Is Unduplicated) 149 376.500000 27511.2500 73.0710
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 4 3.750000 187.5000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 55 231.750000 11587.5000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 2 2.000000 142.8800 71.4400
OCCT-97530GT-OT SESSION BY LICENSED OT 21 37.750000 2696.8600 71.4400
OCCT-97530TL-OT SESSION BY LICENSED OT 1 1.000000 71.4400 71.4400
OCCT-97530TLGT-OT SESSION BY LICENSED OT 52 229.500000 16395.4800 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 38 139.750000 9983.7400 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) 204 885.750000 57825.9400 65.2847
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Total 4897.750000 219593.6900 44.8356
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Number of Children (Unduplicated) With at Least One Service 1009
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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
1915 1684.000000 76868.7800 0.0000
Other 1 1.000000 37.0000 0.0000
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Total 5863 4897.750000 219593.6900 53837.5900