CMS/EIP Fiscal Report Center: 53
Services beginning 07/01/2018 ending 09/30/2018 Date of Report:11/06/2018 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 665 1778.750000 65739.7500 36.9584
Subtotal (Total Children Is Unduplicated) 665 1778.750000 65739.7500 36.9584
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 13 23.000000 1725.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 21 40.000000 3000.0000 75.0000
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 14 30.000000 2250.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 22 41.500000 2303.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 20 35.000000 2625.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 15 24.500000 1837.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 15 19.500000 1462.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 132 228.500000 12626.2500 55.2571
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 143 248.000000 18562.5000 74.8488
Subtotal (Total Children Is Unduplicated) 218 692.000000 46542.0000 67.2572
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EI Services,Class #03
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 12 14.250000 356.2500 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 540 2859.500000 142925.0000 49.9825
OCCT-97530-OT SESSION BY LICENSED OT 6 35.000000 2500.4000 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 1 7.000000 500.0800 71.4400
Subtotal (Total Children Is Unduplicated) 548 2915.750000 146281.7300 50.1695
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Total 5386.500000 258563.4800 48.0021
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Number of Children (Unduplicated) With at Least One Service 862
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Center 53
Flag Claims Units Chgs Paid
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R 160 157.000000 7242.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 1075 1019.000000 45841.7500 0.0000
P 2481 2393.250000 110376.5000 110165.5000
D 0 0.000000 0.0000 0.0000
S 1 0.500000 18.5000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
1714 1813.750000 94884.2300 0.0000
Other 2 3.000000 200.0000 0.0000
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Total 5433 5386.500000 258563.4800 110165.5000