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:TPIN
Eligibility Filter:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
CASE-CASE-NON-TCM CASE MANAGEMENT 1 0.500000 18.5000 37.0000
Subtotal (Total Children Is Unduplicated) 1 0.500000 18.5000 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 1 1.000000 75.0000 75.0000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 3 5.500000 412.5000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 10 16.500000 1237.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 13 20.000000 1500.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 11 18.500000 1387.5000 75.0000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 21 36.500000 2025.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 2 3.500000 262.5000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 12 23.500000 1762.5000 75.0000
Subtotal (Total Children Is Unduplicated) 41 125.000000 8663.2500 69.3060
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 2 2.000000 1026.7600 513.3800
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 4 8.000000 400.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 61 361.500000 18075.6600 50.0018
OCCT-97530-OT SESSION BY LICENSED OT 1 0.500000 35.7200 71.4400
OCCT-97530GT-OT SESSION BY LICENSED OT 28 144.750000 10376.6600 71.6868
OCCT-97530TLGT-OT SESSION BY LICENSED OT 1 3.000000 214.3200 71.4400
PHY-97110-PT SESSION BY LICENSED PT 7 16.750000 1196.6200 71.4400
PHY-97110GT-PT SESSION BY LICENSED PT 19 72.750000 5197.2600 71.4400
PHY-97110TLGT-PT SESSION BY LICENSED PT 2 2.750000 196.4600 71.4400
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 41 228.000000 16288.3200 71.4400
Subtotal (Total Children Is Unduplicated) 145 840.000000 53007.7800 63.1045
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Total 965.500000 61689.5300 63.8939
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Number of Children (Unduplicated) With at Least One Service 163
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Center 54
Flag Claims Units Chgs Paid
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R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 0 0.000000 0.0000 0.0000
P 0 0.000000 0.0000 0.0000
D 28 28.250000 2018.1800 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 141 140.170000 8400.3900 8400.3900
742 770.080000 49342.0800 0.0000
Other 28 27.000000 1928.8800 0.0000
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Total 939 965.500000 61689.5300 8400.3900