CMS/EIP Fiscal Report Center: 52
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 636 1859.750000 68394.5000 36.7762
Subtotal (Total Children Is Unduplicated) 636 1859.750000 68394.5000 36.7762
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 9 18.000000 1350.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 7 14.000000 1050.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 3 6.000000 450.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 13 26.000000 1443.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 118 232.000000 17400.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 93 183.000000 13725.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 24 45.000000 3375.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 155 302.500000 16788.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 8 16.000000 1200.0000 75.0000
OCTH-97166-OT EVAL MODERATE COMPLEXITY 3 3.000000 153.1500 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 1 1.000000 51.0500 51.0500
PSTH-97162-PT EVAL MODERATE COMPLEXITY 1 1.000000 51.0500 51.0500
SCREEN-T1023-SCREENING 20 20.000000 1000.0000 50.0000
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 9 9.000000 459.4500 51.0500
Subtotal (Total Children Is Unduplicated) 201 876.500000 58496.4500 66.7387
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 269 1423.250000 71062.5000 49.9297
OCCT-97530-OT SESSION BY LICENSED OT 37 136.000000 9715.8400 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 12 81.000000 4633.2000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 18 138.750000 9912.3000 71.4400
PHY-97110HM-PT SESSION BY PT ASST 2 6.000000 342.9600 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 80 445.000000 31790.8000 71.4400
Subtotal (Total Children Is Unduplicated) 356 2230.000000 127457.6000 57.1559
-----------------------------------------------------------------------------------------------------------------------
Total 4966.250000 254348.5500 51.2154
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 687
-----------------------------------------------------------------------------------------------------------------------
Center 52
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 7 3.500000 142.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 1090 1102.500000 54661.5000 83.2500
P 2448 2307.750000 104302.3000 103358.9600
D 4 4.000000 221.4400 0.0000
S 6 7.000000 259.0000 0.0000
H 46 43.750000 2955.0300 0.0000
T 2 2.000000 101.0500 101.0500
706 1495.750000 91705.7300 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 4309 4966.250000 254348.5500 103543.2600