CMS/EIP Fiscal Report Center: 01
Services beginning 10/01/2018 ending 12/31/2018 Date of Report:02/06/2019 Page: 1
List order: No List
Agency Filter:EIP DEI DEIP
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 1794 4310.750000 159275.7500 36.9485
Subtotal (Total Children Is Unduplicated) 1794 4310.750000 159275.7500 36.9485
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 6 11.500000 862.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 0.500000 27.7500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 2 3.500000 262.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 59 92.000000 5106.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 190 319.000000 23925.0000 75.0000
Subtotal (Total Children Is Unduplicated) 223 426.500000 30183.7500 70.7708
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 53 197.250000 9862.5000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 3 19.000000 1357.3600 71.4400
PHY-97110-PT SESSION BY LICENSED PT 17 45.000000 3214.8000 71.4400
PHY-97110HM-PT SESSION BY PT ASST 2 3.000000 171.4800 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 10 28.000000 2000.3200 71.4400
Subtotal (Total Children Is Unduplicated) 84 292.250000 16606.4600 56.8228
-----------------------------------------------------------------------------------------------------------------------
Total 5029.500000 206065.9600 40.9715
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 1802
-----------------------------------------------------------------------------------------------------------------------
Center 01
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 600 432.250000 17890.0900 0.0000
U 0 0.000000 0.0000 0.0000
B 700 769.750000 46448.6200 0.0000
P 6002 3806.000000 140666.2500 140456.7000
D 13 8.000000 296.0000 0.0000
S 2 2.000000 74.0000 0.0000
H 2 1.000000 37.0000 37.0000
T 1 0.750000 27.7500 0.0000
8 2.250000 83.2500 0.0000
Other 5 7.500000 543.0000 0.0000
---------------------------------------------------------
Total 7333 5029.500000 206065.9600 140493.7000