CMS/EIP Fiscal Report Center: 53
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 781 1950.750000 71937.2500 36.8767
Subtotal (Total Children Is Unduplicated) 781 1950.750000 71937.2500 36.8767
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 3 4.000000 300.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 5 7.500000 562.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 4 7.000000 525.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 15 23.000000 1276.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 22 39.000000 2925.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 18 31.000000 2325.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 24 36.500000 2737.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 108 196.000000 10850.2500 55.3584
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 90 165.000000 12337.5000 74.7727
SCREEN-T1023-SCREENING 1 1.000000 50.0000 50.0000
Subtotal (Total Children Is Unduplicated) 171 510.000000 33889.2500 66.4495
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 11 15.500000 387.5000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 379 1844.610000 92230.3600 49.9999
OCCT-97530-OT SESSION BY LICENSED OT 35 154.250000 11019.6200 71.4400
PHY-97110-PT SESSION BY LICENSED PT 47 275.500000 19667.4400 71.3882
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 38 168.000000 12001.9200 71.4400
Subtotal (Total Children Is Unduplicated) 479 2457.860000 135306.8400 55.0507
-----------------------------------------------------------------------------------------------------------------------
Total 4918.610000 241133.3400 49.0247
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 912
-----------------------------------------------------------------------------------------------------------------------
Center 53
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 6 6.000000 325.3200 0.0000
U 0 0.000000 0.0000 0.0000
B 2318 2144.110000 102468.7300 186.5000
P 1636 1508.000000 68950.2700 68711.0700
D 32 32.750000 2033.5500 0.0000
S 0 0.000000 0.0000 0.0000
H 43 42.750000 3054.0600 0.0000
T 0 0.000000 0.0000 0.0000
1109 1161.250000 63397.4700 0.0000
Other 34 23.750000 903.9400 0.0000
---------------------------------------------------------
Total 5178 4918.610000 241133.3400 68897.5700