CMS/EIP Fiscal Report Center: 52
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 435 1121.000000 41162.5000 36.7194
Subtotal (Total Children Is Unduplicated) 435 1121.000000 41162.5000 36.7194
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 5 10.000000 750.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 64 124.000000 9300.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 39 77.000000 5635.0000 73.1818
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 7 13.000000 975.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 40 79.000000 4384.5000 55.5000
SCREEN-T1023-SCREENING 10 10.000000 500.0000 50.0000
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 2 2.000000 102.1000 51.0500
Subtotal (Total Children Is Unduplicated) 94 317.000000 21796.6000 68.7590
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 91 468.250000 23412.5000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 4 28.000000 2000.3200 71.4400
PHY-97110-PT SESSION BY LICENSED PT 1 3.000000 214.3200 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 30 108.250000 7733.3800 71.4400
Subtotal (Total Children Is Unduplicated) 121 607.500000 33360.5200 54.9144
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Total 2045.500000 96319.6200 47.0885
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Number of Children (Unduplicated) With at Least One Service 460
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Center 52
Flag Claims Units Chgs Paid
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R 15 12.750000 743.3900 0.0000
U 0 0.000000 0.0000 0.0000
B 260 259.750000 12169.5800 0.0000
P 1710 1709.500000 79037.2400 78957.8500
D 0 0.000000 0.0000 0.0000
S 5 4.500000 255.5000 75.0000
H 38 35.250000 2497.8700 0.0000
T 0 0.000000 0.0000 0.0000
27 23.750000 1616.0400 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 2055 2045.500000 96319.6200 79032.8500