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
Agency Filter:EXT
Payclass Filters:MED
Eligibility Filter:Part C (excluding not eligible)
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Screening, Eval, and Assessment,Class #02
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 1.500000 112.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 1.500000 112.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 17 28.000000 1554.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 2 4.000000 300.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 2 4.000000 300.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 3 4.500000 337.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 97 154.500000 8574.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 16 26.000000 1950.0000 75.0000
Subtotal (Total Children Is Unduplicated) 134 224.000000 13241.2500 59.1127
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 409 2243.250000 112125.0000 49.9833
OCCT-97530-OT SESSION BY LICENSED OT 15 34.750000 2482.5400 71.4400
PHY-97110-PT SESSION BY LICENSED PT 15 54.000000 3857.7600 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 1 3.000000 214.3200 71.4400
Subtotal (Total Children Is Unduplicated) 437 2335.000000 118679.6200 50.8264
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Total 2559.000000 131920.8700 51.5517
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Number of Children (Unduplicated) With at Least One Service 506
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Center 54
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 1 1.500000 83.2500 22.5000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
2481 2557.500000 131837.6200 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 2482 2559.000000 131920.8700 22.5000