CMS/EIP Fiscal Report Center: 09
Services beginning 07/01/2019 ending 09/30/2019 Date of Report:11/04/2019 Page: 1
List order: No List
Agency Filter:EXT
Payclass Filters:OTHER
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 1 1.500000 55.5000 37.0000
Subtotal (Total Children Is Unduplicated) 1 1.500000 55.5000 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 1 1.500000 112.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 3 6.000000 450.0000 75.0000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 2 3.500000 262.5000 75.0000
NUTR-97802-NUTRITIONAL EVAL, INITIAL 1 9.000000 450.0000 50.0000
NUTR-97803-NUTRITIONAL EVAL, FOLLOW-UP 5 49.000000 2450.0000 50.0000
Subtotal (Total Children Is Unduplicated) 12 69.000000 3725.0000 53.9855
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 9 12.500000 625.0000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 4 4.000000 100.0000 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 3 3.000000 150.0000 50.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 1 1.000000 50.0000 50.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 1 1.000000 50.0000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 3 3.000000 150.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 245 1232.000000 61600.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 34 200.000000 14288.0000 71.4400
PHY-97110-PT SESSION BY LICENSED PT 45 233.000000 16645.5200 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 163 902.750000 64492.4600 71.4400
TRAV-TRAVS-Travel by mile 826 51573.00000 22584.5500 0.4379
Subtotal (Total Children Is Unduplicated) 870 54165.25000 180735.5300 3.3367
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Total 54235.750000 184516.0300 3.4021
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Number of Children (Unduplicated) With at Least One Service 875
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Center 09
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 2317 54230.750000 184205.1500 184205.1500
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 2 3.000000 168.0000 0.0000
T 0 0.000000 0.0000 0.0000
1 2.000000 142.8800 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 2320 54235.750000 184516.0300 184205.1500