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
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
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 1 2.000000 150.0000 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 2 3.500000 194.2500 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 6 11.000000 825.0000 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 21 37.000000 2053.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 11 23.000000 1725.0000 75.0000
Subtotal (Total Children Is Unduplicated) 38 115.500000 7872.7500 68.1623
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EI Services,Class #03
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 4 6.000000 150.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 52 246.000000 12300.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 11 41.000000 2864.7200 69.8712
PHY-97110-PT SESSION BY LICENSED PT 17 114.000000 8144.1600 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 35 187.750000 13430.7200 71.5351
SPL-92508-GROUP SPL SESSION PER CHILD 3 3.250000 45.1100 13.8800
Subtotal (Total Children Is Unduplicated) 111 598.000000 36934.7100 61.7637
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Total 754.250000 46315.2100 61.4056
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Number of Children (Unduplicated) With at Least One Service 131
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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 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
362 366.250000 21313.1100 0.0000
Other 355 383.000000 24695.3500 0.0000
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Total 720 754.250000 46315.2100 220.4500