CMS/EIP Fiscal Report Center: 53
Services beginning 07/01/2017 ending 09/30/2017 Date of Report:11/05/2017 Page: 1
List order: No List
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 674 1663.500000 61447.7500 36.9388
Subtotal (Total Children Is Unduplicated) 674 1663.500000 61447.7500 36.9388
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 12 23.500000 1762.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 11 22.000000 1650.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 11 18.000000 1350.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 32 62.000000 3441.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 13 23.000000 1650.0000 71.7391
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 6 9.500000 712.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 2 4.000000 300.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 107 176.500000 9790.2500 55.4688
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 96 164.500000 12337.5000 75.0000
Subtotal (Total Children Is Unduplicated) 162 503.000000 32993.7500 65.5939
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EI Services,Class #03
COUN-H2019HR-INDIVIDUAL/FAMILY THERAPY 10 19.000000 1393.0800 73.3200
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 4 7.000000 175.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 542 2735.750000 136787.5000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 5 17.000000 1214.4800 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 1 3.000000 171.6000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 1 1.000000 71.4400 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 2 4.000000 285.7600 71.4400
Subtotal (Total Children Is Unduplicated) 549 2786.750000 140098.8600 50.2732
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Total 4953.250000 234540.3600 47.3508
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Number of Children (Unduplicated) With at Least One Service 844
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Center 53
Flag Claims Units Chgs Paid
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R 9 7.500000 342.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 348 244.500000 9046.5000 0.0000
P 2613 2479.250000 112639.9400 112639.9400
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
2275 2216.500000 112204.6000 0.0000
Other 4 5.500000 306.8200 0.0000
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Total 5249 4953.250000 234540.3600 112639.9400