CMS/EIP Fiscal Report Center: 52
Services beginning 10/01/2017 ending 12/31/2017 Date of Report:02/03/2018 Page: 1
List order: No List
Payclass Filters:MED
Bill Flag Filter:RBPU
Eligibility Filter:All
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 556 1462.750000 53946.0000 36.8798
Subtotal (Total Children Is Unduplicated) 556 1462.750000 53946.0000 36.8799
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 5 9.500000 712.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 3 6.000000 450.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 1.500000 112.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 9 17.000000 943.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 71 137.500000 10302.5000 74.9273
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 56 111.000000 8325.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 17 31.000000 2325.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 120 232.000000 12844.0000 55.3621
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 2.000000 150.0000 75.0000
SCREEN-T1023-SCREENING 20 20.000000 1000.0000 50.0000
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 1 1.000000 51.0500 51.0500
Subtotal (Total Children Is Unduplicated) 155 568.500000 37216.0500 65.4636
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 134 728.250000 36262.5000 49.7940
OCCT-97530-OT SESSION BY LICENSED OT 11 38.250000 2732.5800 71.4400
PHY-97110-PT SESSION BY LICENSED PT 6 9.500000 678.6800 71.4400
PHY-97110HM-PT SESSION BY PT ASST 3 9.000000 514.4400 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 33 100.000000 7144.0000 71.4400
Subtotal (Total Children Is Unduplicated) 174 885.000000 47332.2000 53.4827
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Total 2916.250000 138494.2500 47.4905
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Number of Children (Unduplicated) With at Least One Service 583
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Center 52
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 75 88.250000 4875.7500 37.0000
P 3045 2828.000000 133618.5000 132310.3000
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
0 0.000000 0.0000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 3120 2916.250000 138494.2500 132347.3000