CMS/EIP Fiscal Report Center: 01
Services beginning 10/01/2016 ending 12/31/2016 Date of Report:02/04/2017 Page: 1
List order: No List
Payclass Filters:MED
Bill Flag Filter:RBPU
Eligibility Filter:All
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 1756 4700.750000 173849.5000 36.9834
Subtotal (Total Children Is Unduplicated) 1756 4700.750000 173849.5000 36.9834
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 0.500000 27.7500 55.5000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 2 3.000000 225.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 2 2.500000 138.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 3 4.000000 300.0000 75.0000
Subtotal (Total Children Is Unduplicated) 8 10.000000 691.5000 69.1500
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1 8.000000 400.0000 50.0000
PHY-97110-PT SESSION BY LICENSED PT 1 5.000000 336.8100 67.3620
PHY-97110HM-PT SESSION BY PT ASST 1 2.000000 114.3200 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 3 8.000000 533.5200 66.6900
Subtotal (Total Children Is Unduplicated) 6 23.000000 1384.6500 60.2022
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Total 4733.750000 175925.6500 37.1641
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Number of Children (Unduplicated) With at Least One Service 1757
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Center 01
Flag Claims Units Chgs Paid
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R 47 22.250000 823.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 7156 4688.000000 173690.0000 0.0000
P 24 23.500000 1412.4000 1412.4000
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
0 0.000000 0.0000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 7227 4733.750000 175925.6500 1412.4000