CMS/EIP Fiscal Report Center: 53
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:Part C (excluding not eligible)
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 684 1803.000000 66535.7500 36.9028
Subtotal (Total Children Is Unduplicated) 684 1803.000000 66535.7500 36.9028
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 11 21.500000 1612.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 18 33.500000 2512.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 1.500000 112.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 7 13.000000 975.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 23 45.500000 2525.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 30 51.500000 3862.5000 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 19 29.500000 2212.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 128 216.000000 11932.5000 55.2431
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 105 184.500000 13800.0000 74.7967
Subtotal (Total Children Is Unduplicated) 198 621.000000 41382.7500 66.6389
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EI Services,Class #03
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 19 28.000000 700.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 584 3078.000000 153900.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 5 17.000000 1214.4800 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 2 11.000000 785.8400 71.4400
SPL-92508-GROUP SPL SESSION PER CHILD 1 1.000000 13.8800 13.8800
Subtotal (Total Children Is Unduplicated) 590 3135.000000 156614.2000 49.9567
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Total 5559.000000 264532.7000 47.5864
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Number of Children (Unduplicated) With at Least One Service 856
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Center 53
Flag Claims Units Chgs Paid
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R 21 18.500000 739.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 773 715.500000 29755.7500 2.0000
P 2656 2680.500000 125552.7500 125515.7500
D 0 0.000000 0.0000 0.0000
S 17 17.750000 720.5000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
2077 2124.750000 107664.2000 0.0000
Other 2 2.000000 100.0000 0.0000
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Total 5546 5559.000000 264532.7000 125517.7500