CMS/EIP Fiscal Report Center: 53
Services beginning 04/01/2019 ending 06/30/2019 Date of Report:07/21/2019 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 15 40.750000 1507.7500 37.0000
Subtotal (Total Children Is Unduplicated) 15 40.750000 1507.7500 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 2.000000 150.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 2 4.000000 300.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 1.500000 112.5000 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 3 5.500000 305.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 13 22.500000 1687.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 10 17.000000 1275.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 8 11.000000 825.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 25 43.000000 2386.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 16 30.000000 2250.0000 75.0000
Subtotal (Total Children Is Unduplicated) 44 138.500000 9441.7500 68.1715
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 2 3.000000 2195.9000 731.9667
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 4 6.000000 150.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 99 585.500000 29275.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 1 1.000000 10.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 23 90.750000 6404.6200 70.5743
OCCT-97530HM-OT SESSION BY OT ASST 5 24.000000 1372.8000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 19 120.000000 8572.8000 71.4400
PHY-97110HM-PT SESSION BY PT ASST 1 1.000000 57.1600 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 36 192.750000 13787.9200 71.5327
SPL-92508-GROUP SPL SESSION PER CHILD 3 3.250000 45.1100 13.8800
TRAV-TRAVS-Travel by mile 1 28.000000 12.4600 0.4450
Subtotal (Total Children Is Unduplicated) 167 1055.250000 61883.7700 58.6437
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Total 1234.500000 72833.2700 58.9982
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Number of Children (Unduplicated) With at Least One Service 185
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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 3 5.000000 306.7500 220.4500
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 29 30.000000 2726.3400 2726.3400
T 0 0.000000 0.0000 0.0000
769 816.500000 45104.8300 0.0000
Other 355 383.000000 24695.3500 0.0000
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Total 1156 1234.500000 72833.2700 2946.7900