CMS/EIP Fiscal Report Center: 01
Services beginning 10/01/2017 ending 12/31/2017 Date of Report:02/03/2018 Page: 1
List order: No List
Payclass Filters:MED
Bill Flag Filter:RBPU
Eligibility Filter:All
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 1767 4643.750000 171585.9900 36.9499
Subtotal (Total Children Is Unduplicated) 1767 4643.750000 171585.9900 36.9499
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 4 6.000000 450.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 3 3.500000 262.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 4 5.500000 412.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 1.500000 83.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 48 64.500000 4837.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 34 50.500000 3787.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 25 36.500000 2737.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 38 52.500000 2913.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 16 20.000000 1500.0000 75.0000
OCTH-97165-OT EVAL LOW COMPLEXITY 2 2.000000 102.1000 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 1 1.000000 51.0500 51.0500
Subtotal (Total Children Is Unduplicated) 149 245.500000 17287.6500 70.4181
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 50 221.500000 11075.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 5 8.000000 571.5200 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 1 2.000000 114.4000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 17 49.000000 3500.5600 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 18 56.000000 4000.6400 71.4400
Subtotal (Total Children Is Unduplicated) 85 336.500000 19262.1200 57.2426
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Total 5225.750000 208135.7600 39.8289
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Number of Children (Unduplicated) With at Least One Service 1774
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Center 01
Flag Claims Units Chgs Paid
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R 4 2.750000 177.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 7546 5116.000000 202441.9600 0.0000
P 104 107.000000 5516.0500 5516.0500
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
0 0.000000 0.0000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 7654 5225.750000 208135.7600 5516.0500