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:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 729 2054.750000 75795.5000 36.8879
Subtotal (Total Children Is Unduplicated) 729 2054.750000 75795.5000 36.8879
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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 8 16.000000 1200.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 25 52.500000 2913.7500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 16 29.000000 2175.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 17 30.000000 2250.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 10 16.000000 1200.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 159 262.500000 14568.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 159 265.000000 19875.0000 75.0000
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 1 1.000000 51.0500 51.0500
Subtotal (Total Children Is Unduplicated) 229 728.500000 48471.0500 66.5354
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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 532 3012.250000 150612.5000 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) 536 3049.250000 152684.2600 50.0727
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Total 5832.500000 276950.8100 47.4841
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Number of Children (Unduplicated) With at Least One Service 873
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Center 53
Flag Claims Units Chgs Paid
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R 1048 972.750000 42853.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 238 175.250000 7001.7500 0.0000
P 1670 1697.750000 77286.0000 77286.0000
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
2870 2984.500000 149726.3100 0.0000
Other 3 2.250000 83.2500 0.0000
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Total 5829 5832.500000 276950.8100 77286.0000