CMS/EIP Fiscal Report Center: 53
Services beginning 04/01/2018 ending 06/30/2018 Date of Report:08/10/2018 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 691 1853.000000 68533.2500 36.9850
Subtotal (Total Children Is Unduplicated) 691 1853.000000 68533.2500 36.9850
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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 13 23.000000 1725.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 7 12.500000 937.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 21 40.000000 2220.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 21 33.500000 2512.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 18 30.000000 2250.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 7 11.000000 825.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 104 177.500000 9851.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 102 183.500000 13762.5000 75.0000
Subtotal (Total Children Is Unduplicated) 162 519.000000 34683.7500 66.8280
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 1 1.000000 362.5500 362.5500
COUN-H2019HR-INDIVIDUAL/FAMILY THERAPY 3 4.000000 293.2800 73.3200
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 18 23.000000 575.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 548 3239.250000 161962.5000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 5 13.000000 928.7200 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 3 11.000000 629.2000 57.2000
Subtotal (Total Children Is Unduplicated) 554 3291.250000 164751.2500 50.0573
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Total 5663.250000 267968.2500 47.3170
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Number of Children (Unduplicated) With at Least One Service 789
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Center 53
Flag Claims Units Chgs Paid
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R 2 1.500000 68.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 16 13.500000 647.5000 0.0000
P 3836 3502.500000 157614.7500 157560.0000
D 0 0.000000 0.0000 0.0000
S 10 8.000000 399.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
2068 2137.750000 109238.5000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 5932 5663.250000 267968.2500 157560.0000