CMS/EIP Fiscal Report Center: 53
Services beginning 07/01/2020 ending 09/30/2020 Date of Report:10/15/2020 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 912 2472.250000 91381.7500 36.9630
Subtotal (Total Children Is Unduplicated) 912 2472.250000 91381.7500 36.9630
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 2 3.500000 262.5000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 2 4.000000 300.0000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 5 9.500000 712.5000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 3 6.000000 450.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 2 4.000000 300.0000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 2 3.500000 262.5000 75.0000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 11 20.500000 1137.7500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 18 34.500000 2587.5000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 41 76.000000 5700.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 9 13.500000 1012.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 43 79.500000 5962.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 27 48.500000 3637.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 2 4.000000 222.0000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 134 267.000000 14763.0000 55.2921
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 69 130.500000 9787.5000 75.0000
SCREEN-T1023-SCREENING 1 3.000000 150.0000 50.0000
Subtotal (Total Children Is Unduplicated) 183 707.500000 47247.7500 66.7813
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 2 1.000000 25.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 24 40.500000 2025.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 302 1430.000000 71500.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 1 1.000000 71.4400 71.4400
OCCT-97530GT-OT SESSION BY LICENSED OT 13 20.750000 1482.3800 71.4400
OCCT-97530TLGT-OT SESSION BY LICENSED OT 50 223.500000 15966.8400 71.4400
PHY-97110GT-PT SESSION BY LICENSED PT 6 11.000000 785.8400 71.4400
PHY-97110TLGT-PT SESSION BY LICENSED PT 33 157.250000 11233.9400 71.4400
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 6 7.750000 553.6600 71.4400
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 41 226.250000 16163.3000 71.4400
Subtotal (Total Children Is Unduplicated) 430 2119.000000 119807.4000 56.5396
-----------------------------------------------------------------------------------------------------------------------
Total 5298.750000 258436.9000 48.7732
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 993
-----------------------------------------------------------------------------------------------------------------------
Center 53
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 19 10.750000 423.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 3469 3093.500000 147584.8000 0.0000
P 1372 1218.500000 58406.9000 58397.6500
D 29 27.750000 1414.2000 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
831 886.500000 47180.3400 0.0000
Other 62 61.750000 3426.9100 9.2500
---------------------------------------------------------
Total 5782 5298.750000 258436.9000 58406.9000