CMS/EIP Fiscal Report Center: 55
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 738 2569.500000 95071.5000 37.0000
Subtotal (Total Children Is Unduplicated) 738 2569.500000 95071.5000 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 4 8.000000 600.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 79 158.000000 11850.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 39 77.500000 5812.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 35 70.000000 5250.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 11 22.000000 1221.0000 55.5000
OCTF-97168-OT RE-EVAL EST PLAN CARE 5 5.000000 255.2500 51.0500
OCTH-97166-OT EVAL MODERATE COMPLEXITY 3 3.000000 153.1500 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 3 3.000000 153.1500 51.0500
PSTH-97162-PT EVAL MODERATE COMPLEXITY 3 3.000000 153.1500 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 2 2.000000 102.1000 51.0500
SPCH-92521-EVAL OF SPEECH FLUENCY 1 1.000000 51.0500 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 5 5.000000 255.2500 51.0500
SPCH-92524-BEHAV & QUAL ANALYSIS OF
VOICE AND RES 1 1.000000 51.0500 51.0500
Subtotal (Total Children Is Unduplicated) 116 362.500000 26207.6500 72.2970
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EI Services,Class #03
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 1 7.000000 175.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 235 1284.250000 64212.5000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 65 371.750000 26557.8200 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 81 521.500000 29829.8000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 47 227.000000 16181.1600 71.2826
PHY-97110HM-PT SESSION BY PT ASST 40 249.000000 14232.8400 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 129 885.750000 63220.4200 71.3750
SPL-92508-GROUP SPL SESSION PER CHILD 4 12.000000 166.5600 13.8800
Subtotal (Total Children Is Unduplicated) 448 3558.250000 214576.1000 60.3038
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Total 6490.250000 335855.2500 51.7477
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Number of Children (Unduplicated) With at Least One Service 752
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Center 55
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 2 0.750000 27.7500 0.0000
P 3499 2960.500000 118787.7500 118787.7500
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
3793 3529.000000 217039.7500 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 7294 6490.250000 335855.2500 118787.7500