CMS/EIP Fiscal Report Center: 54
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 1109 3464.750000 128010.7500 36.9466
Subtotal (Total Children Is Unduplicated) 1109 3464.750000 128010.7500 36.9466
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 12 21.000000 1575.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 9 14.500000 1087.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 1.000000 75.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 10 19.000000 1425.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 19 31.500000 1748.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 95 151.000000 11287.5000 74.7517
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 46 68.000000 5100.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 17 24.500000 1837.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 116 182.500000 10128.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 53 89.500000 6712.5000 75.0000
SCREEN-T1023-SCREENING 8 8.000000 400.0000 50.0000
Subtotal (Total Children Is Unduplicated) 211 610.500000 41377.0000 67.7756
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 503 2679.250000 133925.0000 49.9860
OCCT-97530-OT SESSION BY LICENSED OT 80 360.500000 25739.8800 71.4005
PHY-97110-PT SESSION BY LICENSED PT 74 329.500000 23539.4800 71.4400
PHY-97110HM-PT SESSION BY PT ASST 4 4.000000 228.6400 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 57 282.250000 20163.9400 71.4400
SPL-92508-GROUP SPL SESSION PER CHILD 1 1.000000 13.8800 13.8800
Subtotal (Total Children Is Unduplicated) 683 3656.500000 203610.8200 55.6846
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Total 7731.750000 372998.5700 48.2425
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Number of Children (Unduplicated) With at Least One Service 1145
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Center 54
Flag Claims Units Chgs Paid
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R 106 99.250000 4119.9700 0.0000
U 0 0.000000 0.0000 0.0000
B 2939 2487.000000 119424.4300 108.4400
P 2887 2378.750000 105203.8200 104506.0900
D 91 90.500000 6172.5400 0.0000
S 0 0.000000 0.0000 0.0000
H 38 37.000000 2621.8400 37.0000
T 0 0.000000 0.0000 0.0000
2510 2586.500000 133435.3400 0.0000
Other 71 52.750000 2020.6300 27.7500
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Total 8642 7731.750000 372998.5700 104679.2800