CMS/EIP Fiscal Report Center: 10
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 2041 6189.250000 228923.0000 36.9872
Subtotal (Total Children Is Unduplicated) 2041 6189.250000 228923.0000 36.9872
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 11 22.000000 1650.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 3 5.000000 375.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 2 2.000000 150.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 3 6.000000 450.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 7 13.000000 721.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 237 428.500000 32137.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 117 207.000000 15525.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 53 84.500000 6337.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 237 430.000000 23865.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 111 139.000000 10425.0000 75.0000
SPCH-92524-BEHAV & QUAL ANALYSIS OF
VOICE AND RES 1 1.000000 51.0500 51.0500
Subtotal (Total Children Is Unduplicated) 379 1338.000000 91687.5500 68.5258
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1100 11151.50000 557425.0000 49.9865
OCCT-97530-OT SESSION BY LICENSED OT 19 143.000000 10215.9200 71.4400
PHY-97110-PT SESSION BY LICENSED PT 52 370.500000 26468.5200 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 22 129.500000 9251.4800 71.4400
SPL-92508-GROUP SPL SESSION PER CHILD 1 0.500000 6.9400 13.8800
Subtotal (Total Children Is Unduplicated) 1152 11795.00000 603367.8600 51.1545
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Total 19322.250000 923978.4100 47.8194
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Number of Children (Unduplicated) With at Least One Service 2265
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Center 10
Flag Claims Units Chgs Paid
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R 32 17.750000 656.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 9267 7488.000000 318596.2500 0.0000
P 0 0.000000 0.0000 0.0000
D 0 0.000000 0.0000 0.0000
S 10 17.750000 1204.7500 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
3301 11798.750000 603520.6600 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 12610 19322.250000 923978.4100 0.0000