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:TPIN
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 6 10.500000 388.5000 37.0000
Subtotal (Total Children Is Unduplicated) 6 10.500000 388.5000 37.0000
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Screening, Eval, and Assessment,Class #02
EXIT-EXIT-EXIT ASSESSMENT 1 1.000000 50.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 5 12.000000 750.0000 62.5000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 7 14.000000 777.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 74 175.500000 11133.7100 63.4399
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 34 76.500000 5327.3900 69.6391
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 14 25.500000 1752.7900 68.7369
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 91 177.000000 9805.5000 55.3983
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 2.000000 150.0000 75.0000
OCTH-97166-OT EVAL MODERATE COMPLEXITY 4 4.000000 204.2000 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 2 2.000000 102.1000 51.0500
PSTH-97162-PT EVAL MODERATE COMPLEXITY 3 3.000000 153.1500 51.0500
SCREEN-T1023-SCREENING 11 11.000000 550.0000 50.0000
SPCH-92522-EVAL OF SPCH SOUND PROD 1 1.000000 51.0500 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 5 5.000000 255.2500 51.0500
SPCH-92524-BEHAV & QUAL ANALYSIS OF
VOICE AND RES 1 1.000000 51.0500 51.0500
Subtotal (Total Children Is Unduplicated) 128 512.500000 31263.1900 61.0013
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EI Services,Class #03
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 2 1.000000 0.0000 0.0000
EIIF-EIIF_NM-EI INDIVIDUAL SESSION BY NONMED PROF 1 5.000000 207.0000 41.4000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 97 583.250000 28922.5000 49.5885
OCCT-97530-OT SESSION BY LICENSED OT 32 178.000000 12454.9200 69.9715
OCCT-97530HM-OT SESSION BY OT ASST 4 6.500000 371.8000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 26 170.750000 10662.2800 62.4438
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 123 706.500000 48765.6000 69.0242
TRAV-TRAVS-Travel by mile 1 22.000000 9.7900 0.4450
Subtotal (Total Children Is Unduplicated) 216 1673.000000 101393.8900 60.6060
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Total 2196.000000 133045.5800 60.5854
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Number of Children (Unduplicated) With at Least One Service 289
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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 5 4.000000 148.0000 0.0000
P 81 101.250000 6806.6800 5093.6700
D 75 102.500000 5446.2500 0.0000
S 0 0.000000 0.0000 0.0000
H 95 155.750000 10315.6100 0.0000
T 822 1435.000000 87098.9600 78451.4900
250 397.500000 23230.0800 298.0500
Other 0 0.000000 0.0000 0.0000
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Total 1328 2196.000000 133045.5800 83843.2100