CMS/EIP Fiscal Report Center: 53
Services beginning 01/01/2019 ending 03/31/2019 Date of Report:05/04/2019 Page: 1
List order: No List
Agency Filter:EIP DEI DEIP
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
CASE-CASE-NON-TCM CASE MANAGEMENT 1 2.750000 101.7500 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 1 2.500000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 12 20.000000 740.0000 37.0000
Subtotal (Total Children Is Unduplicated) 12 25.250000 841.7500 33.3366
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Screening, Eval, and Assessment,Class #02
EXIT-EXIT-EXIT ASSESSMENT 1 1.000000 50.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 2.000000 150.0000 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 3 5.500000 297.0000 54.0000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 14 26.000000 1950.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 1 1.500000 112.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 5 8.500000 637.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 39 68.999999 3801.7500 55.0978
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 25 45.500000 3412.5000 75.0000
Subtotal (Total Children Is Unduplicated) 52 160.999999 10561.2500 65.5978
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EI Services,Class #03
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 1 1.000000 50.0000 50.0000
COUN-H2019HR-INDIVIDUAL/FAMILY THERAPY 1 2.000000 146.6400 73.3200
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 1 1.500000 0.0000 0.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 3 4.000000 100.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 66 252.500000 12625.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 1 1.000000 10.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 7 34.000000 2414.7200 71.0212
PHY-97110-PT SESSION BY LICENSED PT 14 106.000000 7576.2200 71.4738
PHY-97110HM-PT SESSION BY PT ASST 3 7.000000 400.1200 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 27 97.500000 6901.0800 70.7803
SPL-92508-GROUP SPL SESSION PER CHILD 5 6.000000 83.2800 13.8800
Subtotal (Total Children Is Unduplicated) 99 512.500000 30307.0600 59.1357
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Total 698.749999 41710.0600 59.6924
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Number of Children (Unduplicated) With at Least One Service 132
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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 20 19.028672 1040.7400 1682.9700
D 19 20.085585 1063.0000 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
564 609.885742 36767.8000 0.0000
Other 42 49.750000 2838.5200 0.0000
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Total 645 698.749999 41710.0600 1682.9700