CMS/EIP Fiscal Report Center: 09
Services beginning 01/01/2016 ending 03/31/2016 Date of Report:05/12/2016 Page: 1
List order: No List
Payclass Filters:TPIN
Eligibility Filter:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 1 0.500000 0.0000 0.0000
Subtotal (Total Children Is Unduplicated) 1 0.500000 0.0000 0.0000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 3 5.000000 375.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 1.500000 112.5000 75.0000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 37 53.000000 3975.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 28 37.500000 2812.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 10 14.000000 1050.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 1 1.500000 83.2500 55.5000
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 1 1.000000 51.0500 51.0500
Subtotal (Total Children Is Unduplicated) 72 113.500000 8459.3000 74.5313
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1 1.000000 50.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 17 79.000000 5643.7600 71.4400
PHY-97110-PT SESSION BY LICENSED PT 26 168.000000 11931.4800 71.0207
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 20 133.000000 9329.9200 70.1498
Subtotal (Total Children Is Unduplicated) 59 381.000000 26955.1600 70.7485
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Total 495.000000 35414.4600 71.5444
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Number of Children (Unduplicated) With at Least One Service 129
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Center 09
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 164 164.500000 11764.3400 270829.0300
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 0 0.000000 0.0000 0.0000
174 330.500000 23650.1200 300.5400
Other 0 0.000000 0.0000 0.0000
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Total 338 495.000000 35414.4600 271129.5700