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
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 781 1950.750000 71937.2500 36.8767
Subtotal (Total Children Is Unduplicated) 781 1950.750000 71937.2500 36.8767
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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 1 1.500000 112.5000 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 13 19.000000 1054.5000 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 9 17.000000 1275.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 19 27.500000 2062.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 65 112.500000 6216.0000 55.2533
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 78 144.000000 10762.5000 74.7396
SCREEN-T1023-SCREENING 1 1.000000 50.0000 50.0000
Subtotal (Total Children Is Unduplicated) 159 372.500000 25283.0000 67.8738
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EI Services,Class #03
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 11 14.500000 362.5000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 198 991.110000 49555.3600 49.9999
OCCT-97530-OT SESSION BY LICENSED OT 23 103.000000 7358.3200 71.4400
PHY-97110-PT SESSION BY LICENSED PT 34 203.500000 14523.7600 71.3698
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 26 124.000000 8858.5600 71.4400
Subtotal (Total Children Is Unduplicated) 274 1436.110000 80658.5000 56.1646
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Total 3759.360000 177878.7500 47.3162
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Number of Children (Unduplicated) With at Least One Service 857
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Center 53
Flag Claims Units Chgs Paid
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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
2 2.000000 142.8800 0.0000
Other 34 23.750000 903.9400 0.0000
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Total 4071 3759.360000 177878.7500 68897.5700