CMS/EIP Fiscal Report Center: 09
Services beginning 01/01/2018 ending 03/31/2018 Date of Report:05/05/2018 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 1013 3423.750000 126678.7500 37.0000
Subtotal (Total Children Is Unduplicated) 1013 3423.750000 126678.7500 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 5 9.500000 712.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 2 3.000000 225.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 4 6.500000 487.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 8 13.500000 1012.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 3 6.000000 333.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 146 222.500000 16672.5000 74.9326
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 33 49.500000 3712.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 128 209.000000 15650.0000 74.8804
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 177 296.000000 16339.2000 55.2000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 114 169.500000 12677.5000 74.7935
OCTH-97167-OT EVAL HIGH COMPLEXITY 1 1.000000 51.0500 51.0500
Subtotal (Total Children Is Unduplicated) 310 986.000000 67873.2500 68.8370
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EI Services,Class #03
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 1 1.000000 25.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 740 5264.500000 263225.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 41 307.000000 21932.0800 71.4400
PHY-97110-PT SESSION BY LICENSED PT 43 342.000000 24432.4800 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 86 715.000000 51079.6000 71.4400
Subtotal (Total Children Is Unduplicated) 829 6629.500000 360694.1600 54.4074
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Total 11039.250000 555246.1600 50.2975
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Number of Children (Unduplicated) With at Least One Service 1228
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Center 09
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 28 29.750000 1150.9500 50.0000
P 3861 4189.000000 174916.2500 175826.7520
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
2069 6493.500000 355190.2100 0.0000
Other 204 327.000000 23988.7500 0.0000
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Total 6162 11039.250000 555246.1600 175876.7520