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:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 735 2033.500000 75064.2500 36.9138
Subtotal (Total Children Is Unduplicated) 735 2033.500000 75064.2500 36.9138
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 14 26.000000 1950.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 20 36.000000 2700.0000 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 27 51.500000 2858.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 41 68.500000 5137.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 19 31.000000 2325.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 20 31.500000 2362.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 164 275.000000 15151.5000 55.0964
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 131 224.000000 16762.5000 74.8326
Subtotal (Total Children Is Unduplicated) 243 758.000000 50334.7500 66.4047
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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 585 3083.000000 154150.0000 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) 591 3140.000000 156864.2000 49.9568
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Total 5931.500000 282263.2000 47.5872
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Number of Children (Unduplicated) With at Least One Service 913
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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 837 789.000000 32932.5000 29.7500
P 2858 2922.500000 136970.5000 136933.5000
D 0 0.000000 0.0000 0.0000
S 19 19.250000 776.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
2121 2180.250000 110744.7000 0.0000
Other 2 2.000000 100.0000 0.0000
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Total 5858 5931.500000 282263.2000 136963.2500