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: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 20 29.000000 1073.0000 37.0000
Subtotal (Total Children Is Unduplicated) 20 29.000000 1073.0000 37.0000
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Screening, Eval, and Assessment,Class #02
EXIT-EXIT-EXIT ASSESSMENT 1 1.250000 62.5000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 5 9.000000 675.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 4 10.000000 750.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 1.500000 150.0000 100.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 1.500000 83.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 1 1.500000 112.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 4 7.500000 562.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 2 2.500000 187.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 42 68.000000 3774.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 44 72.500000 5437.5000 75.0000
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 1 1.000000 51.0500 51.0500
Subtotal (Total Children Is Unduplicated) 61 176.250000 11845.8000 67.2102
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EI Services,Class #03
COUN-H2019HR-INDIVIDUAL/FAMILY THERAPY 1 1.000000 73.3200 73.3200
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 3 2.000000 0.0000 0.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 1 1.000000 25.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 124 623.250000 31162.5000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 6 36.000000 2571.8400 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 1 1.000000 57.2000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 3 7.000000 500.0800 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 7 28.000000 2000.3200 71.4400
SPL-92508-GROUP SPL SESSION PER CHILD 1 2.000000 27.7600 13.8800
Subtotal (Total Children Is Unduplicated) 134 701.250000 36418.0200 51.9330
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Total 906.500000 49336.8200 54.4256
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Number of Children (Unduplicated) With at Least One Service 170
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Center 53
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 0 0.000000 0.0000 0.0000
P 32 35.084190 2106.8698 842.6200
D 4 5.000000 295.7500 0.0000
S 0 0.000000 0.0000 0.0000
H 34 35.000000 2211.2400 2211.2400
T 10 10.000000 564.3200 564.3200
749 798.915810 42832.0102 0.0000
Other 17 22.500000 1326.6300 0.0000
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Total 846 906.500000 49336.8200 3618.1800