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:TPIN
Eligibility Filter:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
CASE-CASE-NON-TCM CASE MANAGEMENT 3 1.250000 46.2500 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 9 14.250000 527.2500 37.0000
Subtotal (Total Children Is Unduplicated) 11 15.500000 573.5000 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 3 6.000000 450.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 3 6.000000 450.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 6 11.000000 610.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 80 176.000000 11944.8600 67.8685
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 53 103.500000 7762.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 26 51.000000 3595.5800 70.5016
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 96 188.500000 10451.4000 55.4451
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 4 10.000000 600.0000 60.0000
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 14 14.000000 700.0000 50.0000
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 4 4.000000 204.2000 51.0500
Subtotal (Total Children Is Unduplicated) 130 575.000000 37024.2900 64.3901
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 110 600.500000 29712.0000 49.4788
OCCT-97530-OT SESSION BY LICENSED OT 43 169.500000 11241.0800 66.3191
OCCT-97530HM-OT SESSION BY OT ASST 14 72.250000 3903.9000 54.0332
PHY-97110-PT SESSION BY LICENSED PT 20 113.250000 7233.3000 63.8702
PHY-97110HM-PT SESSION BY PT ASST 1 5.000000 285.8000 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 117 724.250000 46538.8800 64.2580
Subtotal (Total Children Is Unduplicated) 255 1684.750000 98914.9600 58.7120
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Total 2275.250000 136512.7500 59.9990
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Number of Children (Unduplicated) With at Least One Service 321
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Center 52
Flag Claims Units Chgs Paid
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R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 0 0.000000 0.0000 0.0000
P 75 79.750000 5456.8700 3661.3100
D 32 48.250000 2639.9100 60.0000
S 0 0.000000 0.0000 0.0000
H 138 233.250000 15679.1100 0.0000
T 785 1224.750000 73068.0300 66215.9400
452 689.250000 39668.8300 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 1482 2275.250000 136512.7500 69937.2500