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
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 583 1574.750000 58090.0000 36.8884
Subtotal (Total Children Is Unduplicated) 583 1574.750000 58090.0000 36.8884
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 6 11.500000 862.5000 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-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 2 3.500000 262.5000 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 103 199.000000 14915.0000 74.9497
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 57 113.000000 8475.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 24 45.000000 3375.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 121 234.000000 12955.0000 55.3632
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 13 26.000000 1950.0000 75.0000
OCTH-97166-OT EVAL MODERATE COMPLEXITY 1 1.000000 51.0500 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 1 1.000000 51.0500 51.0500
SCREEN-T1023-SCREENING 22 22.000000 1100.0000 50.0000
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 14 14.000000 713.6500 50.9750
Subtotal (Total Children Is Unduplicated) 172 694.500000 46216.7500 66.5468
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 259 1543.500000 77025.0000 49.9028
OCCT-97530-OT SESSION BY LICENSED OT 44 196.750000 14031.4600 71.3162
OCCT-97530HM-OT SESSION BY OT ASST 7 26.000000 1487.2000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 23 107.750000 7697.6600 71.4400
PHY-97110HM-PT SESSION BY PT ASST 3 23.000000 1314.6800 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 95 473.000000 33601.1200 71.0383
Subtotal (Total Children Is Unduplicated) 349 2370.000000 135157.1200 57.0283
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Total 4639.250000 239463.8700 51.6169
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Number of Children (Unduplicated) With at Least One Service 627
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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 63 56.750000 3070.3600 0.0000
S 38 33.250000 1452.2500 0.0000
H 53 50.000000 3416.9800 0.0000
T 1 4.000000 200.0000 0.0000
799 1579.000000 92830.0300 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 4074 4639.250000 239463.8700 132347.3000