CMS/EIP Fiscal Report Center: 53
Services beginning 07/01/2017 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 1682 8206.750000 303253.0000 36.9517
Subtotal (Total Children Is Unduplicated) 1682 8206.750000 303253.0000 36.9517
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 41 81.500000 6112.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 54 102.500000 7612.5000 74.2683
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 2 4.000000 300.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 35 64.500000 4837.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 105 209.000000 11599.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 87 145.000000 10800.0000 74.4828
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 68 115.000000 8625.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 22 33.500000 2512.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 592 988.527020 54807.7496 55.4439
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 569 998.000000 74811.0000 74.9609
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 1 1.000000 51.0500 51.0500
Subtotal (Total Children Is Unduplicated) 831 2742.527020 182069.2996 66.3874
-----------------------------------------------------------------------------------------------------------------------
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 28 48.000000 1200.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 963 11980.00000 599000.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 11 72.000000 5143.6800 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 3 17.000000 972.4000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 1 1.000000 71.4400 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 1 1.000000 71.4400 71.4400
Subtotal (Total Children Is Unduplicated) 970 12124.00000 607114.7900 50.0755
-----------------------------------------------------------------------------------------------------------------------
Total 23073.277020 1092437.0896 47.3464
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 1762
-----------------------------------------------------------------------------------------------------------------------
Center 53
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 2 1.500000 68.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 368 246.000000 9310.7500 9.2500
P 15065 14288.513510 644756.7598 644701.2600
D 0 0.000000 0.0000 0.0000
S 13 11.000000 510.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
8155 8526.263510 437791.0798 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 23603 23073.277020 1092437.0896 644710.5100