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:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 751 2087.250000 77200.5000 36.9867
Subtotal (Total Children Is Unduplicated) 751 2087.250000 77200.5000 36.9867
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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 11 20.000000 1500.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 25 47.500000 2636.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 28 43.500000 3262.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 23 36.500000 2737.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 10 14.500000 1087.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 139 232.000000 12876.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 135 246.000000 18450.0000 75.0000
Subtotal (Total Children Is Unduplicated) 211 671.000000 44874.7500 66.8774
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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 550 3242.250000 162112.5000 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) 556 3294.250000 164901.2500 50.0573
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Total 6052.500000 286976.5000 47.4145
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Number of Children (Unduplicated) With at Least One Service 852
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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 17 13.750000 656.7500 9.2500
P 4163 3847.750000 174021.0000 173966.2500
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
2099 2181.500000 111831.2500 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 6291 6052.500000 286976.5000 173975.5000