CMS/EIP Fiscal Report Center: 06
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 1254 2994.750000 110805.7500 37.0000
Subtotal (Total Children Is Unduplicated) 1254 2994.750000 110805.7500 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 5 7.500000 562.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 1.500000 112.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 6 9.000000 499.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 198 307.000000 23025.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 54 86.500000 6487.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 82 128.000000 9600.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 196 307.500000 17066.2500 55.5000
Subtotal (Total Children Is Unduplicated) 271 847.000000 57353.2500 67.7134
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 715 5174.000000 258660.0000 49.9923
OCCT-97530-OT SESSION BY LICENSED OT 41 132.250000 9447.9400 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 10 29.500000 1687.4000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 16 60.000000 4286.4000 71.4400
PHY-97110HM-PT SESSION BY PT ASST 4 7.000000 400.1200 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 40 157.500000 11251.8000 71.4400
Subtotal (Total Children Is Unduplicated) 780 5560.250000 285733.6600 51.3886
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Total 9402.000000 453892.6600 48.2762
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Number of Children (Unduplicated) With at Least One Service 1425
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Center 06
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 3.000000 111.0000 111.0000
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
10865 9399.000000 453781.6600 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 10868 9402.000000 453892.6600 111.0000