CMS/EIP Fiscal Report Center: 54
Services beginning 10/01/2017 ending 12/31/2017 Date of Report:02/03/2018 Page: 1
List order: No List
Payclass Filters:MED
Bill Flag Filter:RBPU
Eligibility Filter:All
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 1094 2645.000000 97633.7500 36.9126
Subtotal (Total Children Is Unduplicated) 1094 2645.000000 97633.7500 36.9126
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 13 22.500000 1687.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 6 9.500000 712.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 2 3.500000 262.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 10 18.000000 1350.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 9 15.000000 832.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 109 174.000000 12975.0000 74.5690
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 29 38.000000 2850.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 5 6.000000 450.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 66 91.500000 5078.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 38 58.000000 4350.0000 75.0000
SCREEN-T1023-SCREENING 4 4.000000 200.0000 50.0000
Subtotal (Total Children Is Unduplicated) 226 440.000000 30748.2500 69.8824
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 223 957.500000 47875.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 2 4.000000 285.7600 71.4400
PHY-97110-PT SESSION BY LICENSED PT 6 11.000000 785.8400 71.4400
Subtotal (Total Children Is Unduplicated) 227 972.500000 48946.6000 50.3307
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Total 4057.500000 177328.6000 43.7039
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Number of Children (Unduplicated) With at Least One Service 1130
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Center 54
Flag Claims Units Chgs Paid
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R 1535 1276.500000 53894.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 3381 2781.000000 123434.3500 0.0000
P 0 0.000000 0.0000 0.0000
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
0 0.000000 0.0000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 4916 4057.500000 177328.6000 0.0000