CMS/EIP Fiscal Report Center: 53
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:Part C (excluding not eligible)
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 658 1798.250000 66305.0000 36.8720
Subtotal (Total Children Is Unduplicated) 658 1798.250000 66305.0000 36.8720
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 11 21.500000 1612.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 16 31.000000 2325.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 2 4.000000 300.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 6 12.000000 900.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 23 47.500000 2636.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 14 25.500000 1912.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 14 25.000000 1875.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 8 13.000000 975.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 104 175.000000 9712.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 105 178.000000 13350.0000 75.0000
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 1 1.000000 51.0500 51.0500
Subtotal (Total Children Is Unduplicated) 165 533.500000 35649.8000 66.8225
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EI Services,Class #03
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 8 12.000000 300.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 529 3000.250000 150012.5000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 6 24.000000 1714.5600 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 1 1.000000 57.2000 57.2000
Subtotal (Total Children Is Unduplicated) 533 3037.250000 152084.2600 50.0730
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Total 5369.000000 254039.0600 47.3159
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Number of Children (Unduplicated) With at Least One Service 795
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Center 53
Flag Claims Units Chgs Paid
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R 947 870.500000 38154.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 214 153.250000 6103.0000 0.0000
P 1548 1543.000000 69463.7500 69463.7500
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
2718 2800.250000 140243.8100 0.0000
Other 2 2.000000 74.0000 0.0000
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Total 5429 5369.000000 254039.0600 69463.7500