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
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 1775 5063.500000 187225.0000 36.9754
Subtotal (Total Children Is Unduplicated) 1775 5063.500000 187225.0000 36.9754
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 8 12.500000 937.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 4 5.500000 412.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 8 12.000000 900.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 8 10.500000 582.7500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 76 108.000000 8100.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 41 57.000000 4275.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 31 50.000000 3750.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 67 97.500000 5411.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 61 92.500000 6937.5000 75.0000
PSTH-97001-EVAL BY LICENSED PT, INITIAL 1 1.000000 51.0500 51.0500
SPCH-92521-EVAL OF SPEECH FLUENCY 2 2.000000 102.1000 51.0500
Subtotal (Total Children Is Unduplicated) 201 448.500000 31459.6500 70.1441
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 44 174.000000 8700.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 9 32.000000 2286.0800 71.4400
PHY-97110-PT SESSION BY LICENSED PT 22 69.000000 4908.9700 71.1445
PHY-97110HM-PT SESSION BY PT ASST 2 4.000000 228.6400 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 18 60.250000 4244.8200 70.4534
Subtotal (Total Children Is Unduplicated) 94 339.250000 20368.5100 60.0398
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Total 5851.250000 239053.1600 40.8551
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Number of Children (Unduplicated) With at Least One Service 1779
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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 170 229.000000 15250.8400 0.0000
S 845 866.000000 46629.1000 0.0000
H 0 0.000000 0.0000 0.0000
T 3 3.000000 214.3200 214.3200
29 19.500000 1033.2500 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 8274 5851.250000 239053.1600 1626.7200