CMS/EIP Fiscal Report Center: 09
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 1033 3496.250000 129361.2500 37.0000
Subtotal (Total Children Is Unduplicated) 1033 3496.250000 129361.2500 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 2 2.500000 187.5000 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 4.500000 337.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 3 4.500000 337.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 2 3.500000 194.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 120 186.500000 13987.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 67 97.000000 7275.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 81 134.000000 10050.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 146 241.000000 13375.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 80 116.000000 8700.0000 75.0000
OCTH-97167-OT EVAL HIGH COMPLEXITY 1 1.000000 51.0500 51.0500
Subtotal (Total Children Is Unduplicated) 240 792.500000 54645.8000 68.9537
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 724 5048.750000 252437.5000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 47 338.000000 24146.7200 71.4400
PHY-97110-PT SESSION BY LICENSED PT 51 376.000000 26861.4400 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 109 849.000000 60652.5600 71.4400
Subtotal (Total Children Is Unduplicated) 839 6611.750000 364098.2200 55.0684
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Total 10900.500000 548105.2700 50.2826
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Number of Children (Unduplicated) With at Least One Service 1173
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Center 09
Flag Claims Units Chgs Paid
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R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 56 61.750000 3084.7500 0.0000
P 4095 4180.250000 172755.7500 172784.0070
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
2037 6435.500000 355949.2700 0.0000
Other 140 223.000000 16315.5000 0.0000
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Total 6328 10900.500000 548105.2700 172784.0070