CMS/EIP Fiscal Report Center: 57
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 801 2813.000000 104081.0000 37.0000
Subtotal (Total Children Is Unduplicated) 801 2813.000000 104081.0000 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 10 10.000000 750.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 1.000000 75.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 9 9.000000 499.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 170 181.500000 13612.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 153 183.000000 10156.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 34 39.500000 2962.5000 75.0000
OCTH-97167-OT EVAL HIGH COMPLEXITY 2 2.000000 102.1000 51.0500
PSTF-97164-PT RE-EVAL EST PLAN CARE 1 1.000000 51.0500 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 3 3.000000 153.1500 51.0500
SPCH-92522-EVAL OF SPCH SOUND PROD 1 1.000000 51.0500 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 1 1.000000 51.0500 51.0500
Subtotal (Total Children Is Unduplicated) 194 432.000000 28464.4000 65.8898
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 654 5124.500000 256225.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 8 39.500000 2821.8800 71.4400
PHY-97110-PT SESSION BY LICENSED PT 7 23.000000 1643.1200 71.4400
PHY-97110HM-PT SESSION BY PT ASST 5 38.000000 2172.0800 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 2 5.500000 392.9200 71.4400
Subtotal (Total Children Is Unduplicated) 664 5230.500000 263255.0000 50.3308
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Total 8475.500000 395800.4000 46.6994
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Number of Children (Unduplicated) With at Least One Service 1014
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Center 57
Flag Claims Units Chgs Paid
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R 1 0.500000 18.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 2298 2819.500000 106232.2500 0.0000
P 365 381.750000 23505.0000 23315.8000
D 1 1.000000 75.0000 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
1540 5272.750000 265969.6500 265941.9000
Other 0 0.000000 0.0000 0.0000
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Total 4205 8475.500000 395800.4000 289257.7000