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:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 740 1929.250000 71280.5000 36.9473
Subtotal (Total Children Is Unduplicated) 740 1929.250000 71280.5000 36.9473
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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 12 24.000000 1800.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 12 19.000000 1425.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 33 63.000000 3496.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 18 30.500000 2212.5000 72.5410
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 4 7.000000 525.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 149 236.000000 13092.5000 55.4767
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 139 227.000000 17025.0000 75.0000
Subtotal (Total Children Is Unduplicated) 211 639.500000 42051.5000 65.7568
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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 545 2754.750000 137737.5000 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) 552 2805.750000 141048.8600 50.2714
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Total 5374.500000 254380.8600 47.3311
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Number of Children (Unduplicated) With at Least One Service 915
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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 407 295.500000 10933.5000 0.0000
P 2862 2767.250000 126091.9400 126091.9400
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
2351 2298.750000 116706.1000 0.0000
Other 4 5.500000 306.8200 0.0000
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Total 5633 5374.500000 254380.8600 126091.9400