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:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 1242 3817.250000 140581.5000 36.8280
Subtotal (Total Children Is Unduplicated) 1242 3817.250000 140581.5000 36.8280
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 32 56.000000 4200.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 11 17.500000 1312.5000 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 20 36.500000 2737.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 35 56.000000 3108.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 200 320.000000 23925.0000 74.7656
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 57 78.000000 5850.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 17 19.500000 1462.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 229 351.000000 19480.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 67 102.000000 7650.0000 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) 344 1049.500000 70527.0500 67.2006
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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 9335.500000 436602.0900 46.7679
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Number of Children (Unduplicated) With at Least One Service 1275
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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
5320 5278.000000 259273.4900 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 10236 9335.500000 436602.0900 0.0000