CMS/EIP Fiscal Report Center: 53
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 727 2054.000000 75961.0000 36.9820
Subtotal (Total Children Is Unduplicated) 727 2054.000000 75961.0000 36.9820
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 13 27.000000 2025.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 11 21.500000 1537.5000 71.5116
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 9 15.500000 1162.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 24 42.500000 2358.7500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 18 31.000000 2325.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 20 34.000000 2550.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 5 8.500000 637.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 133 236.500000 13070.2500 55.2653
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 140 257.000000 19236.0000 74.8482
Subtotal (Total Children Is Unduplicated) 209 675.500000 45052.5000 66.6950
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EI Services,Class #03
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 4 4.000000 100.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 473 2634.500000 131725.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 5 17.000000 1214.4800 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 1 6.000000 343.2000 57.2000
Subtotal (Total Children Is Unduplicated) 476 2661.500000 133382.6800 50.1156
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Total 5391.000000 254396.1800 47.1891
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Number of Children (Unduplicated) With at Least One Service 817
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Center 53
Flag Claims Units Chgs Paid
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R 2 2.000000 74.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 348 233.000000 8621.0000 0.0000
P 3312 3188.250000 144028.2500 144028.2500
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
1852 1964.500000 101552.6800 0.0000
Other 4 3.250000 120.2500 0.0000
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Total 5518 5391.000000 254396.1800 144028.2500