CMS/EIP Fiscal Report Center: 53
Services beginning 07/01/2019 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 1997 8929.250000 329947.5000 36.9513
Subtotal (Total Children Is Unduplicated) 1997 8929.250000 329947.5000 36.9513
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 13 21.000000 1575.0000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 4 5.000000 375.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 9 14.500000 1087.5000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 2 4.000000 300.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 16 24.000000 1800.0000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 20 35.000000 2587.5000 73.9286
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 5 10.000000 750.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 46 76.000000 4218.0000 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 6 11.500000 638.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 78 136.500000 10162.5000 74.4505
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 36 64.000000 4800.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 111 186.500000 13987.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 35 64.500000 4837.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 102 167.500000 12562.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 21 36.500000 2737.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 442 772.000000 42762.7500 55.3922
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 116 205.000000 11322.0000 55.2293
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 312 560.500000 42000.0000 74.9331
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 65 121.000000 9075.0000 75.0000
OCTF-97168-OT RE-EVAL EST PLAN CARE 1 1.000000 51.0500 51.0500
SCREEN-T1023-SCREENING 3 4.000000 200.0000 50.0000
SPCH-92523TL-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 1 1.000000 51.0500 51.0500
SPCH-92523TLGT-EVAL OF SPCH SOUND PROD; EVAL LANG COM 1 1.000000 51.0500 51.0500
Subtotal (Total Children Is Unduplicated) 774 2524.000000 168081.6500 66.5934
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EI Services,Class #03
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 37 117.000000 2925.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 722 7092.710000 354559.8000 49.9893
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 341 1657.750000 82887.5000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 70 526.250000 37581.0600 71.4129
OCCT-97530GT-OT SESSION BY LICENSED OT 27 83.000000 5929.5200 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 1 1.000000 57.2000 57.2000
OCCT-97530TL-OT SESSION BY LICENSED OT 3 12.000000 857.2800 71.4400
OCCT-97530TLGT-OT SESSION BY LICENSED OT 39 131.500000 9394.3600 71.4400
PHY-97110-PT SESSION BY LICENSED PT 78 753.750000 53691.6600 71.2327
PHY-97110GT-PT SESSION BY LICENSED PT 24 57.000000 4072.0800 71.4400
PHY-97110TL-PT SESSION BY LICENSED PT 9 16.250000 1160.9000 71.4400
PHY-97110TLGT-PT SESSION BY LICENSED PT 31 155.500000 11048.0800 71.0487
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 71 472.500000 33697.8400 71.3182
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 25 40.500000 2893.3200 71.4400
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 7 18.000000 1285.9200 71.4400
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 35 128.000000 9144.3200 71.4400
SPL-92508-GROUP SPL SESSION PER CHILD 3 2.000000 27.7600 13.8800
SPL-92508TLGT-SPL THERAPY SESSION BY LICENSED SLP 3 2.500000 34.7000 13.8800
Subtotal (Total Children Is Unduplicated) 989 11267.21000 611248.3000 54.2502
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Total 22720.460000 1109277.4500 48.8228
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Number of Children (Unduplicated) With at Least One Service 2061
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Center 53
Flag Claims Units Chgs Paid
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R 39 30.500000 1548.0900 0.0000
U 0 0.000000 0.0000 0.0000
B 3617 3156.750000 151650.4000 149.1900
P 12547 11551.710000 533301.5200 534595.8900
D 644 575.000000 34249.9300 0.0000
S 0 0.000000 0.0000 0.0000
H 43 42.500000 2827.1600 50.0000
T 0 0.000000 0.0000 0.0000
6994 7154.750000 371395.5400 0.0000
Other 215 209.250000 14304.8100 0.0000
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Total 24099 22720.460000 1109277.4500 534795.0800