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:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 1096 3698.250000 136835.2500 37.0000
Subtotal (Total Children Is Unduplicated) 1096 3698.250000 136835.2500 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 4 5.500000 412.5000 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 4 6.000000 450.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 4 6.000000 450.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 4 6.500000 360.7500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 146 224.000000 16800.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 79 112.500000 8437.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 108 176.000000 13200.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 184 301.000000 16705.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 101 143.500000 10762.5000 75.0000
OCTH-97167-OT EVAL HIGH COMPLEXITY 1 1.000000 51.0500 51.0500
Subtotal (Total Children Is Unduplicated) 303 984.000000 67779.8000 68.8819
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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 11294.000000 568713.2700 50.3553
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Number of Children (Unduplicated) With at Least One Service 1240
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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 4284 4501.250000 188004.2500 188032.5070
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
2042 6444.000000 356586.7700 0.0000
Other 184 287.000000 21037.5000 0.0000
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Total 6566 11294.000000 568713.2700 188032.5070