CMS/EIP Fiscal Report Center: 01
Services beginning 10/01/2019 ending 12/31/2019 Date of Report:02/01/2020 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 1713 5179.250000 191632.2500 37.0000
Subtotal (Total Children Is Unduplicated) 1713 5179.250000 191632.2500 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 7 11.500000 862.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 23 56.500000 4237.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 5 9.000000 499.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 23 30.500000 2287.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 15 20.500000 1537.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 21 30.500000 2287.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 110 162.000000 8991.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 177 289.500000 21712.5000 75.0000
OCTH-97166-OT EVAL MODERATE COMPLEXITY 1 1.000000 51.0500 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 2 2.000000 102.1000 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 2 2.000000 102.1000 51.0500
SPCH-92521-EVAL OF SPEECH FLUENCY 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) 283 617.000000 42772.8500 69.3239
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 109 433.500000 21675.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 24 123.000000 8787.1200 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 2 4.000000 228.8000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 38 213.000000 15216.7200 71.4400
PHY-97110HM-PT SESSION BY PT ASST 5 14.000000 800.2400 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 29 124.000000 8858.5600 71.4400
SPL-92508-GROUP SPL SESSION PER CHILD 4 10.000000 138.8000 13.8800
Subtotal (Total Children Is Unduplicated) 182 921.500000 55705.2400 60.4506
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Total 6717.750000 290110.3400 43.1856
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Number of Children (Unduplicated) With at Least One Service 1730
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Center 01
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 201 200.750000 14300.8000 0.0000
P 0 0.000000 0.0000 0.0000
D 0 0.000000 0.0000 0.0000
S 2391 1769.000000 76842.7300 0.0000
H 6550 4741.250000 198682.6200 198557.6000
T 0 0.000000 0.0000 0.0000
13 6.750000 284.1900 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 9155 6717.750000 290110.3400 198557.6000