CMS/EIP Fiscal Report Center: 01
Services beginning 07/01/2019 ending 09/30/2019 Date of Report:11/04/2019 Page: 1
List order: No List
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 1826 5196.250000 192205.7500 36.9893
Subtotal (Total Children Is Unduplicated) 1826 5196.250000 192205.7500 36.9893
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 10 16.500000 1237.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 3 6.000000 450.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 21 54.000000 4050.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 6 8.500000 471.7500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 108 147.500000 11062.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 10 14.500000 1087.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 19 29.500000 2212.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 246 388.500000 21561.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 191 347.000000 26025.0000 75.0000
OCTH-97167-OT EVAL HIGH COMPLEXITY 2 2.000000 102.1000 51.0500
PSTH-97162-PT EVAL MODERATE COMPLEXITY 3 3.000000 153.1500 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 3 3.000000 153.1500 51.0500
Subtotal (Total Children Is Unduplicated) 346 1020.000000 68566.9000 67.2225
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 153 654.500000 32725.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 26 140.250000 10019.4600 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 1 6.000000 343.2000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 43 180.250000 12874.0600 71.4234
PHY-97110HM-PT SESSION BY PT ASST 5 12.000000 685.9200 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 37 132.500000 8877.4100 66.9993
SPL-92508-GROUP SPL SESSION PER CHILD 4 17.000000 235.9600 13.8800
Subtotal (Total Children Is Unduplicated) 241 1142.500000 65761.0100 57.5589
-----------------------------------------------------------------------------------------------------------------------
Total 7358.750000 326533.6600 44.3735
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 1851
-----------------------------------------------------------------------------------------------------------------------
Center 01
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 197 209.500000 12124.8500 0.0000
P 4 3.000000 111.0000 111.0000
D 125 127.500000 6239.0600 0.0000
S 3536 2676.000000 122028.9300 0.0000
H 5768 3974.250000 162623.6300 162623.6300
T 1 0.500000 18.5000 0.0000
28 14.000000 552.4400 0.0000
Other 242 354.000000 22835.2500 0.0000
---------------------------------------------------------
Total 9901 7358.750000 326533.6600 162734.6300