CMS/EIP Fiscal Report Center: 55
Services beginning 01/01/2020 ending 03/31/2020 Date of Report:05/15/2020 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 3 7.000000 259.0000 37.0000
Subtotal (Total Children Is Unduplicated) 3 7.000000 259.0000 37.0000
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 1 2.000000 150.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 2 4.000000 300.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 1 2.000000 111.0000 55.5000
Subtotal (Total Children Is Unduplicated) 3 8.000000 561.0000 70.1250
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 1 3.750000 93.7500 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 7 44.000000 2200.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 3 11.000000 785.8400 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 5 16.000000 915.2000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 4 21.000000 1500.2400 71.4400
PHY-97110GT-PT SESSION BY LICENSED PT 1 2.000000 142.8800 71.4400
PHY-97110HM-PT SESSION BY PT ASST 2 5.000000 285.8000 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 13 47.000000 3357.6800 71.4400
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 3 3.750000 267.9000 71.4400
Subtotal (Total Children Is Unduplicated) 29 153.500000 9549.2900 62.2104
-----------------------------------------------------------------------------------------------------------------------
Total 168.500000 10369.2900 61.5388
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 32
-----------------------------------------------------------------------------------------------------------------------
Center 55
Flag Claims Units Chgs Paid
---------------------------------------------------------
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 59 62.000000 4211.7600 4211.7600
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
107 106.500000 6157.5300 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 166 168.500000 10369.2900 4211.7600