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:OTHER
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 407 982.750000 36361.7500 37.0000
Subtotal (Total Children Is Unduplicated) 407 982.750000 36361.7500 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 1.000000 75.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 1.000000 55.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 4 5.000000 375.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 4 6.000000 333.0000 55.5000
Subtotal (Total Children Is Unduplicated) 5 13.000000 838.5000 64.5000
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EI Services,Class #03
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 2 2.000000 100.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 15 44.000000 2200.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 20 59.000000 590.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 1 3.500000 250.0400 71.4400
PHY-97110-PT SESSION BY LICENSED PT 1 2.500000 178.6000 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 3 12.500000 893.0000 71.4400
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 1 3.000000 171.6000 57.2000
Subtotal (Total Children Is Unduplicated) 25 126.500000 4383.2400 34.6501
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Total 1122.250000 41583.4900 37.0537
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Number of Children (Unduplicated) With at Least One Service 430
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Center 57
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 0 0.000000 0.0000 0.0000
D 0 0.000000 0.0000 0.0000
S 7 6.500000 298.6000 298.6000
H 0 0.000000 0.0000 0.0000
T 1 4.000000 200.0000 200.0000
872 995.750000 37200.2500 0.0000
Other 50 116.000000 3884.6400 3884.6400
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Total 930 1122.250000 41583.4900 4383.2400