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:TPIN
Eligibility Filter:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 4 7.500000 562.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 5 9.500000 712.5000 75.0000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 29 42.000000 3150.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 7 9.000000 675.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 20 31.000000 2325.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 21 31.500000 1748.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 24 36.500000 2737.5000 75.0000
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 2 2.000000 102.1000 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 1 1.000000 51.0500 51.0500
Subtotal (Total Children Is Unduplicated) 80 170.000000 12063.9000 70.9641
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 2 2.000000 100.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 19 61.750000 3087.5000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 1 1.000000 10.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 1 3.000000 214.3200 71.4400
PHY-97110-PT SESSION BY LICENSED PT 15 55.000000 3929.2000 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 19 69.000000 4929.3600 71.4400
TRAV-TRAVS-Travel by mile 1 33.000000 14.6900 0.4452
Subtotal (Total Children Is Unduplicated) 54 224.750000 12285.0700 54.6610
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Total 394.750000 24348.9700 61.6820
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Number of Children (Unduplicated) With at Least One Service 126
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Center 01
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 19 20.750000 1129.3200 1129.3200
D 130 158.000000 10568.7400 0.0000
S 123 137.500000 9329.2700 0.0000
H 30 39.500000 2944.7000 0.0000
T 3 36.000000 181.1900 181.1900
2 3.000000 195.7500 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 307 394.750000 24348.9700 1310.5100