CMS/EIP Fiscal Report Center: 55
Services beginning 07/01/2019 ending 09/30/2019 Date of Report:11/04/2019 Page: 1
List order: No List
Payclass Filters:OTHER
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 2 8.000000 296.0000 37.0000
Subtotal (Total Children Is Unduplicated) 2 8.000000 296.0000 37.0000
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Screening, Eval, and Assessment,Class #02
OCTH-97167-OT EVAL HIGH COMPLEXITY 1 1.000000 51.0500 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 1 1.000000 51.0500 51.0500
Subtotal (Total Children Is Unduplicated) 2 2.000000 102.1000 51.0500
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EI Services,Class #03
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 1 1.500000 37.5000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1 6.000000 300.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 1 19.000000 1357.3600 71.4400
PHY-97110HM-PT SESSION BY PT ASST 2 12.000000 685.9200 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 3 15.000000 1071.6000 71.4400
Subtotal (Total Children Is Unduplicated) 5 53.500000 3452.3800 64.5305
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Total 63.500000 3850.4800 60.6375
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Number of Children (Unduplicated) With at Least One Service 5
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Center 55
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 0 0.000000 0.0000 0.0000
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
66 63.500000 3850.4800 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 66 63.500000 3850.4800 0.0000