CMS/EIP Fiscal Report Center: 02
Services beginning 01/01/2016 ending 03/31/2016 Date of Report:05/12/2016 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 531 1027.500000 38017.5000 37.0000
Subtotal (Total Children Is Unduplicated) 531 1027.500000 38017.5000 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 2 4.000000 222.0000 55.5000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 47 90.000000 4995.0000 55.5000
Subtotal (Total Children Is Unduplicated) 49 94.000000 5217.0000 55.5000
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EI Services,Class #03
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 1 2.000000 50.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 52 273.250000 13662.5000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 1 17.000000 1214.4800 71.4400
PHY-97110-PT SESSION BY LICENSED PT 6 24.000000 1607.4000 66.9750
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 6 28.000000 2000.3200 71.4400
Subtotal (Total Children Is Unduplicated) 62 344.250000 18534.7000 53.8408
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Total 1465.750000 61769.2000 42.1417
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Number of Children (Unduplicated) With at Least One Service 546
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Center 02
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 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 18 18.000000 1228.7600 541.4700
68 70.000000 4515.4400 0.0000
Other 1824 1377.750000 56025.0000 0.0000
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Total 1910 1465.750000 61769.2000 541.4700