CMS/EIP Fiscal Report Center: 57
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 1039 4783.250000 176980.2500 37.0000
Subtotal (Total Children Is Unduplicated) 1039 4783.250000 176980.2500 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 3 4.000000 300.0000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 10 12.000000 900.0000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 1 1.500000 112.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 1.500000 112.5000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 4 3.500000 262.5000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 2 2.500000 187.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 4 5.500000 305.2500 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 13 15.000000 832.5000 55.5000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 66 85.500000 6412.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 18 25.000000 1875.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 1 1.500000 112.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 44 58.500000 4387.5000 75.0000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 118 161.000000 8935.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 1.500000 112.5000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 7 9.000000 675.0000 75.0000
PSTH-97163-PT EVAL HIGH COMPLEXITY 1 1.000000 51.0500 51.0500
PSTH-97163GT-PT EVAL HIGH COMPLEXITY 1 1.000000 51.0500 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 1 1.000000 51.0500 51.0500
Subtotal (Total Children Is Unduplicated) 149 390.500000 25676.4000 65.7526
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 36 102.000000 5100.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 464 2481.000000 124050.0000 50.0000
OCCT-97530GT-OT SESSION BY LICENSED OT 4 19.000000 1357.3600 71.4400
PHY-97110GT-PT SESSION BY LICENSED PT 1 13.000000 928.7200 71.4400
PHY-97110HMGT-PT SESSION BY LICENSED PT ASST 1 0.750000 42.8700 57.1600
PHY-97110TLGT-PT SESSION BY LICENSED PT 1 0.500000 35.7200 71.4400
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 2 2.000000 142.8800 71.4400
Subtotal (Total Children Is Unduplicated) 484 2618.250000 131657.5500 50.2846
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Total 7792.000000 334314.2000 42.9048
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Number of Children (Unduplicated) With at Least One Service 1046
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Center 57
Flag Claims Units Chgs Paid
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R 1 0.250000 9.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 687 798.250000 31330.7500 157.2500
P 4331 4370.250000 171013.5000 168361.8000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 2 2.000000 150.0000 0.0000
T 0 0.000000 0.0000 0.0000
863 2621.250000 131810.7000 131810.7000
Other 0 0.000000 0.0000 0.0000
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Total 5884 7792.000000 334314.2000 300329.7500