CMS/EIP Fiscal Report Center: 57
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 789 2434.750000 90085.7500 37.0000
Subtotal (Total Children Is Unduplicated) 789 2434.750000 90085.7500 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 5 5.500000 412.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 0.500000 37.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 1.000000 55.5000 55.5000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 7 6.500000 360.7500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 130 106.000000 7950.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 13 12.500000 937.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 195 187.500000 10406.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 70 69.500000 5212.5000 75.0000
OCTF-97168-OT RE-EVAL EST PLAN CARE 2 2.000000 102.1000 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 7 7.000000 357.3500 51.0500
PSTF-97164-PT RE-EVAL EST PLAN CARE 1 1.000000 51.0500 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 3 3.000000 153.1500 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 13 13.000000 663.6500 51.0500
Subtotal (Total Children Is Unduplicated) 234 415.000000 26699.8000 64.3369
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EI Services,Class #03
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 1 8.000000 200.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 588 4610.000000 230500.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 12 55.318300 3951.9400 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 1 2.000000 114.4000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 16 55.500000 3964.9200 71.4400
PHY-97110HM-PT SESSION BY PT ASST 5 39.750000 2272.1100 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 5 24.500000 1750.2800 71.4400
Subtotal (Total Children Is Unduplicated) 618 4795.068300 242753.6500 50.6257
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Total 7644.818300 359539.2000 47.0304
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Number of Children (Unduplicated) With at Least One Service 1019
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Center 57
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 2494 2567.000000 102851.0000 0.0000
P 249 220.250000 10285.6400 10285.6900
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 2 6.000000 300.0000 300.0000
1369 4851.568300 246102.5600 245701.3100
Other 0 0.000000 0.0000 0.0000
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Total 4114 7644.818300 359539.2000 256287.0000