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:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 1042 3875.250000 143082.0000 36.9220
Subtotal (Total Children Is Unduplicated) 1042 3875.250000 143082.0000 36.9220
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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 8 13.000000 950.0000 73.0769
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 11 20.000000 1110.0000 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 63 110.000000 8212.5000 74.6591
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 53 89.500000 6712.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 34 56.500000 4237.5000 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 106 185.000000 10267.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 5 7.500000 562.5000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 69 127.500000 9562.5000 75.0000
SCREEN-T1023-SCREENING 10 10.000000 500.0000 50.0000
Subtotal (Total Children Is Unduplicated) 186 664.500000 45449.5000 68.3965
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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 7847.500000 368599.1200 46.9703
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Number of Children (Unduplicated) With at Least One Service 1061
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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 60 38.500000 1450.3300 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
4585 4426.000000 216496.4600 0.0000
Other 1 1.000000 37.0000 0.0000
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Total 8722 7847.500000 368599.1200 57294.5900