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
Agency Filter:EIP DEI DEIP
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
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 4 7.000000 525.0000 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 4 5.500000 305.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 12 18.000000 1350.0000 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 98 149.000000 8269.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 168 287.500000 21562.5000 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 2 2.000000 102.1000 51.0500
Subtotal (Total Children Is Unduplicated) 263 578.000000 40169.6000 69.4976
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 114 530.000000 26500.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 21 114.250000 8162.0200 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 1 6.000000 343.2000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 40 176.750000 12627.0200 71.4400
PHY-97110HM-PT SESSION BY PT ASST 5 12.000000 685.9200 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 32 117.500000 8394.2000 71.4400
SPL-92508-GROUP SPL SESSION PER CHILD 4 17.000000 235.9600 13.8800
Subtotal (Total Children Is Unduplicated) 192 973.500000 56948.3200 58.4985
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Total 6747.750000 289323.6700 42.8771
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Number of Children (Unduplicated) With at Least One Service 1843
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Center 01
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 197 209.500000 12124.8500 0.0000
P 4 3.000000 111.0000 111.0000
D 2 2.000000 121.4400 0.0000
S 3434 2544.500000 113771.8100 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 0 0.000000 0.0000 0.0000
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Total 9434 6747.750000 289323.6700 162734.6300