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
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 1716 4509.750000 166627.9900 36.9484
Subtotal (Total Children Is Unduplicated) 1716 4509.750000 166627.9900 36.9484
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 8 12.000000 900.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 2 4.000000 300.0000 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 7 9.500000 712.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 8 12.500000 693.7500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 97 137.500000 10312.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 31 47.000000 3525.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 30 44.500000 3337.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 90 131.500000 7298.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 39 49.000000 3675.0000 75.0000
OCTH-97165-OT EVAL LOW COMPLEXITY 2 2.000000 102.1000 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 1 1.000000 51.0500 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 2 2.000000 102.1000 51.0500
Subtotal (Total Children Is Unduplicated) 204 456.000000 31272.2500 68.5795
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 75 332.500000 16625.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 10 35.000000 2446.8200 69.9091
OCCT-97530HM-OT SESSION BY OT ASST 1 3.000000 171.6000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 24 94.000000 6715.3600 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 40 189.750000 13555.7400 71.4400
SPL-92508-GROUP SPL SESSION PER CHILD 3 12.000000 166.5600 13.8800
Subtotal (Total Children Is Unduplicated) 137 666.250000 39681.0800 59.5588
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Total 5632.000000 237581.3200 42.1842
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Number of Children (Unduplicated) With at Least One Service 1731
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Center 01
Flag Claims Units Chgs Paid
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R 3 0.750000 27.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 7275 4870.250000 192545.4600 0.0000
P 102 104.500000 5357.8000 5357.8000
D 179 181.750000 11897.5500 0.0000
S 162 138.750000 7062.4300 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
82 100.500000 6569.3600 0.0000
Other 193 235.500000 14120.9700 0.0000
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Total 7996 5632.000000 237581.3200 5357.8000