CMS/EIP Fiscal Report Center: 53
Services beginning 10/01/2018 ending 12/31/2018 Date of Report:02/06/2019 Page: 1
List order: No List
Payclass Filters:TPIN
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 3 5.500000 203.5000 37.0000
Subtotal (Total Children Is Unduplicated) 3 5.500000 203.5000 37.0000
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Screening, Eval, and Assessment,Class #02
ASTE-ASTE-ASSISTIVE TECHNOLOGY EVAL 1 1.000000 48.5000 48.5000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 5 10.000000 750.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 9 17.500000 1312.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 2.000000 150.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 5 11.000000 638.2500 58.0227
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 4 7.500000 562.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 12 19.000000 1425.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 33 58.000000 3219.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 23 39.500000 2962.5000 75.0000
Subtotal (Total Children Is Unduplicated) 53 165.500000 11068.2500 66.8776
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EI Services,Class #03
COUN-H2019HR-INDIVIDUAL/FAMILY THERAPY 1 4.000000 293.2800 73.3200
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 2 2.000000 50.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 157 840.000000 42000.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 1 1.000000 10.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 10 36.749992 2625.4192 71.4400
SENS-V5264-EARMOLD 1 2.000000 36.0000 18.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 1 4.000000 285.7600 71.4400
TRAV-TRAVS-Travel by mile 2 6.000000 2.6800 0.4467
Subtotal (Total Children Is Unduplicated) 166 895.749992 45303.1392 50.5757
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Total 1066.749992 56574.8892 53.0348
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Number of Children (Unduplicated) With at Least One Service 192
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Center 53
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 0 0.000000 0.0000 0.0000
P 44 33.820600 1689.5300 1833.6700
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 68 64.037512 3493.8600 3493.8600
T 44 47.000000 2578.9600 2578.9600
656 695.391880 36186.5692 0.0000
Other 199 226.500000 12625.9700 0.0000
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Total 1011 1066.749992 56574.8892 7906.4900