CMS/EIP Fiscal Report Center: 01
Services beginning 10/01/2018 ending 12/31/2018 Date of Report:02/06/2019 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 1854 4517.000000 166907.0000 36.9509
Subtotal (Total Children Is Unduplicated) 1854 4517.000000 166907.0000 36.9509
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
AUDE-92557-COMP AUDIO THRESHOLD EVAL/SPCH RECOG 1 3.000000 51.5500 17.1833
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 2 3.500000 262.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 8 14.500000 1087.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 6 8.500000 471.7500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 59 97.000000 7275.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 222 342.000000 18981.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 237 403.000000 30225.0000 75.0000
Subtotal (Total Children Is Unduplicated) 293 871.500000 58354.3000 66.9585
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 223 546.250000 27312.5000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 4 21.000000 1500.2400 71.4400
PHY-97110-PT SESSION BY LICENSED PT 35 78.000000 5572.3200 71.4400
PHY-97110HM-PT SESSION BY PT ASST 2 3.000000 171.4800 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 15 38.000000 2696.8600 70.9700
Subtotal (Total Children Is Unduplicated) 272 686.250000 37253.4000 54.2855
-----------------------------------------------------------------------------------------------------------------------
Total 6074.750000 262514.7000 43.2141
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 1904
-----------------------------------------------------------------------------------------------------------------------
Center 01
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 616 441.250000 18223.0900 0.0000
U 0 0.000000 0.0000 0.0000
B 744 823.000000 50248.6200 0.0000
P 6372 4131.500000 154549.8300 151640.2800
D 120 119.000000 5885.8300 0.0000
S 11 14.500000 861.1300 0.0000
H 2 1.000000 37.0000 37.0000
T 1 0.750000 27.7500 0.0000
9 2.750000 101.7500 0.0000
Other 406 541.000000 32579.7000 0.0000
---------------------------------------------------------
Total 8281 6074.750000 262514.7000 151677.2800