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: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 3 2.500000 92.5000 37.0000
Subtotal (Total Children Is Unduplicated) 3 2.500000 92.5000 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 3 4.500000 337.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 11 28.000000 2100.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 5 12.500000 693.7500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 3 4.500000 337.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 3 3.500000 262.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 2 3.000000 225.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 27 36.500000 2025.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 55 95.000000 7125.0000 75.0000
SPCH-92522-EVAL OF SPCH SOUND PROD 1 1.000000 51.0500 51.0500
SPCH-92610-EVAL OF ORAL,PHARYNGEAL SWALLOWING FUNC 1 1.000000 48.9400 48.9400
Subtotal (Total Children Is Unduplicated) 83 189.500000 13206.9900 69.6939
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 39 172.250000 8612.5000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 13 84.500000 6036.6800 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 1 3.750000 214.5000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 17 90.250000 6447.4600 71.4400
PHY-97110HM-PT SESSION BY PT ASST 1 10.000000 571.6000 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 31 145.250000 10319.1000 71.0437
SPL-92508-GROUP SPL SESSION PER CHILD 3 13.000000 180.4400 13.8800
Subtotal (Total Children Is Unduplicated) 85 519.000000 32382.2800 62.3936
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Total 711.000000 45681.7700 64.2500
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Number of Children (Unduplicated) With at Least One Service 166
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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 0 0.000000 0.0000 0.0000
P 0 0.000000 0.0000 0.0000
D 1 1.000000 50.0000 0.0000
S 203 218.500000 13780.2100 0.0000
H 332 367.250000 24672.0800 0.0000
T 0 0.000000 0.0000 0.0000
120 124.250000 7179.4800 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 656 711.000000 45681.7700 0.0000