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:TPIN
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 26 47.500000 1757.5000 37.0000
Subtotal (Total Children Is Unduplicated) 26 47.500000 1757.5000 37.0000
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Screening, Eval, and Assessment,Class #02
EXIT-EXIT-EXIT ASSESSMENT 1 2.000000 100.0000 50.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 2 2.000000 111.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 9 15.500000 1162.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 3 3.500000 262.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 1 1.500000 112.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 23 38.000000 2109.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 21 35.000000 2625.0000 75.0000
Subtotal (Total Children Is Unduplicated) 39 97.500000 6482.5000 66.4872
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EI Services,Class #03
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 2 1.250000 0.0000 0.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 3 4.000000 100.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 48 254.890000 12744.6400 50.0005
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 1 1.000000 10.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 13 63.000000 4486.4800 71.2140
PHY-97110-PT SESSION BY LICENSED PT 17 121.250000 8662.1000 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 25 159.000000 11358.9600 71.4400
Subtotal (Total Children Is Unduplicated) 100 604.390000 37362.1800 61.8180
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Total 749.390000 45602.1800 60.8524
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Number of Children (Unduplicated) With at Least One Service 141
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Center 53
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 31 26.630000 1668.4900 2807.0700
D 24 24.000000 1457.2800 0.0000
S 1 0.250000 9.2500 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
547 564.510000 34148.1600 0.0000
Other 133 134.000000 8319.0000 0.0000
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Total 736 749.390000 45602.1800 2807.0700