CMS/EIP Fiscal Report Center: 55
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 779 2594.750000 96005.7500 37.0000
Subtotal (Total Children Is Unduplicated) 779 2594.750000 96005.7500 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 2 4.000000 300.0000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 1 2.000000 150.0000 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 3 6.000000 450.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 94 192.670133 14450.2600 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 12 24.000000 1800.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 37 76.000000 5700.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 3 6.000000 333.0000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 38 76.000000 4218.0000 55.5000
OCTF-97168-OT RE-EVAL EST PLAN CARE 1 1.000000 51.0500 51.0500
OCTF-97168GT-OT RE-EVAL EST PLAN CARE 2 2.000000 102.1000 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 5 5.000000 255.2500 51.0500
OCTH-97167GT-OT EVAL HIGH COMPLEXITY 3 3.000000 153.1500 51.0500
OCTH-97167TLGT-OT EVAL HIGH COMPLEXITY 1 1.000000 51.0500 51.0500
PSTF-97164-PT RE-EVAL EST PLAN CARE 1 1.000000 51.0500 51.0500
PSTH-97163GT-PT EVAL HIGH COMPLEXITY 2 2.000000 102.1000 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 7 7.000000 357.3500 51.0500
SPCH-92523GT-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 2 2.000000 102.1000 51.0500
SPCH-92523TL-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 3 3.000000 153.1500 51.0500
SPCH-92610-EVAL OF ORAL,PHARYNGEAL SWALLOWING FUNC 1 1.000000 48.9400 48.9400
Subtotal (Total Children Is Unduplicated) 126 418.670133 29089.5500 69.4808
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 134 702.750000 35137.5000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 118 475.750000 23787.5000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 34 187.250000 13377.1400 71.4400
OCCT-97530GT-OT SESSION BY LICENSED OT 16 81.000000 5786.6400 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 36 88.250000 5047.9000 57.2000
OCCT-97530HMGT-OT SESSION BY OT ASST 16 82.500000 4719.0000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 18 82.000000 5858.0800 71.4400
PHY-97110GT-PT SESSION BY LICENSED PT 4 11.250000 803.7000 71.4400
PHY-97110HM-PT SESSION BY PT ASST 19 104.000000 5944.6400 57.1600
PHY-97110HMGT-PT SESSION BY LICENSED PT ASST 4 17.500000 1000.3000 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 86 491.750000 35130.6200 71.4400
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 21 72.750000 5197.2600 71.4400
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 12 75.250000 5375.8600 71.4400
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 5 25.750000 1839.5800 71.4400
Subtotal (Total Children Is Unduplicated) 386 2497.750000 149005.7200 59.6560
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Total 5511.170133 274101.0200 49.7355
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Number of Children (Unduplicated) With at Least One Service 792
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Center 55
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 2270 1790.083333 77216.8400 92.5000
P 2079 1265.250000 49181.3100 50033.4100
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
2481 2455.000000 147640.1100 0.0000
Other 1 0.836800 62.7600 0.0000
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Total 6831 5511.170133 274101.0200 50125.9100