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:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 1776 4732.250000 174860.4900 36.9508
Subtotal (Total Children Is Unduplicated) 1776 4732.250000 174860.4900 36.9508
-----------------------------------------------------------------------------------------------------------------------
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 4 5.000000 375.0000 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 9 14.500000 804.7500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 109 152.500000 11437.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 36 54.000000 4050.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 35 51.500000 3862.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 103 148.000000 8214.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 45 56.500000 4237.5000 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) 231 512.500000 35149.0000 68.5834
-----------------------------------------------------------------------------------------------------------------------
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
-----------------------------------------------------------------------------------------------------------------------
Total 5911.000000 249690.5700 42.2417
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 1791
-----------------------------------------------------------------------------------------------------------------------
Center 01
Flag Claims Units Chgs Paid
---------------------------------------------------------
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 179 181.750000 11897.5500 0.0000
S 168 142.750000 7324.4300 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
94 113.750000 7485.8600 0.0000
Other 201 247.000000 14846.9700 0.0000
---------------------------------------------------------
Total 8296 5911.000000 249690.5700 5516.0500