CMS/EIP Fiscal Report Center: 52
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: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
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 1 0.750000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 10 23.500000 795.5000 33.8511
Subtotal (Total Children Is Unduplicated) 10 24.250000 795.5000 32.8041
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 3 8.000000 510.0000 63.7500
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 4.000000 230.0000 57.5000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 2.000000 111.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 43 103.000000 6704.6500 65.0937
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 32 86.000000 5541.6600 64.4379
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 15 29.000000 1609.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 4.000000 227.7200 56.9300
SCREEN-T1023-SCREENING 10 10.000000 500.0000 50.0000
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 5 5.000000 255.2500 51.0500
Subtotal (Total Children Is Unduplicated) 65 253.000000 15839.7800 62.6078
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 51 284.500000 14225.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 2 16.000000 1143.0400 71.4400
PHY-97110-PT SESSION BY LICENSED PT 1 1.000000 71.4400 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 35 186.750000 12987.0000 69.5422
Subtotal (Total Children Is Unduplicated) 84 488.250000 28426.4800 58.2212
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Total 765.500000 45061.7600 58.8658
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Number of Children (Unduplicated) With at Least One Service 126
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Center 52
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 76 104.000000 7089.6000 4690.6600
D 0 0.000000 0.0000 0.0000
S 5 5.000000 185.0000 0.0000
H 67 97.000000 6871.9200 0.0000
T 352 373.500000 20740.2500 14339.7100
176 186.000000 10174.9900 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 676 765.500000 45061.7600 19030.3700