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:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 834 2972.750000 109991.7500 37.0000
Subtotal (Total Children Is Unduplicated) 834 2972.750000 109991.7500 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 6 12.000000 900.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 4 8.000000 600.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 2.000000 111.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 128 254.000000 19050.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 70 138.000000 10350.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 54 106.000000 7950.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 21 42.000000 2331.0000 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) 180 587.000000 42616.1500 72.5999
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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 42 262.000000 14975.9200 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) 450 3571.250000 215319.1800 60.2924
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Total 7131.000000 367927.0800 51.5954
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Number of Children (Unduplicated) With at Least One Service 848
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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 3 1.250000 46.2500 0.0000
P 3894 3459.250000 140965.5000 140965.5000
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
3885 3670.500000 226915.3300 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 7782 7131.000000 367927.0800 140965.5000