CMS/EIP Fiscal Report Center: 09
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 1277 4346.000000 160626.2500 36.9596
Subtotal (Total Children Is Unduplicated) 1277 4346.000000 160626.2500 36.9596
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 3 5.000000 375.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 3 4.500000 337.5000 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 5 8.000000 600.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 2 3.500000 194.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 158 254.000000 19050.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 46 72.000000 5400.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 115 195.000000 14625.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 190 329.000000 18259.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 93 140.500000 10537.5000 75.0000
Subtotal (Total Children Is Unduplicated) 300 1013.500000 69528.7500 68.6026
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 842 5799.000000 289650.0000 49.9483
OCCT-97530-OT SESSION BY LICENSED OT 42 312.000000 22289.2800 71.4400
PHY-97110-PT SESSION BY LICENSED PT 66 491.000000 35077.0400 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 130 924.000000 66010.5600 71.4400
SPL-92508-GROUP SPL SESSION PER CHILD 1 4.000000 55.5200 13.8800
Subtotal (Total Children Is Unduplicated) 981 7530.000000 413082.4000 54.8582
-----------------------------------------------------------------------------------------------------------------------
Total 12889.500000 643237.4000 49.9040
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 1423
-----------------------------------------------------------------------------------------------------------------------
Center 09
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 202 241.250000 8926.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 1776 1734.250000 68773.0000 124.5000
P 3023 3148.000000 131004.7500 130894.8900
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
2393 7398.500000 407574.4000 0.0000
Other 225 367.500000 26959.0000 0.0000
---------------------------------------------------------
Total 7619 12889.500000 643237.4000 131019.3900