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
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 1113 3288.000000 121064.0000 36.8200
Subtotal (Total Children Is Unduplicated) 1113 3288.000000 121064.0000 36.8200
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 22 40.000000 3000.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 9 14.500000 1087.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 4 6.000000 450.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 15 28.500000 2137.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 22 35.500000 1970.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 130 221.500000 16537.5000 74.6614
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 36 49.500000 3712.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 12 16.000000 1200.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 150 242.000000 13431.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 47 74.500000 5587.5000 75.0000
OCTH-97167-OT EVAL HIGH COMPLEXITY 1 1.000000 51.0500 51.0500
SCREEN-T1023-SCREENING 6 6.000000 300.0000 50.0000
Subtotal (Total Children Is Unduplicated) 231 735.000000 49464.8000 67.2990
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EI Services,Class #03
COUN-H2019HR-INDIVIDUAL/FAMILY THERAPY 3 6.000000 439.9200 73.3200
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 1 1.000000 25.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 711 4345.750000 217287.5000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 7 35.000000 2500.4000 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 2 6.000000 343.2000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 19 56.000000 4000.6400 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 6 11.000000 785.8400 71.4400
SPL-92508-GROUP SPL SESSION PER CHILD 4 8.000000 111.0400 13.8800
Subtotal (Total Children Is Unduplicated) 734 4468.750000 225493.5400 50.4601
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Total 8491.750000 396022.3400 46.6361
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Number of Children (Unduplicated) With at Least One Service 1144
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Center 54
Flag Claims Units Chgs Paid
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R 1385 1119.750000 47042.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 3048 2463.750000 108226.8500 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
5011 4908.250000 240753.2400 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 9444 8491.750000 396022.3400 0.0000