CMS/EIP Fiscal Report Center: 06
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:Part C (excluding not eligible)
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 1026 2673.750000 98744.5000 36.9311
Subtotal (Total Children Is Unduplicated) 1026 2673.750000 98744.5000 36.9311
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 6 11.000000 825.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 3 6.000000 450.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 7 13.000000 721.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 125 192.000000 14400.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 53 84.000000 6300.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 148 230.500000 12792.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 18 29.000000 2175.0000 75.0000
Subtotal (Total Children Is Unduplicated) 180 565.500000 37664.2500 66.6034
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 390 1964.250000 98212.5000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 20 52.000000 3714.8800 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 6 17.750000 1015.3000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 35 75.500000 5393.7200 71.4400
PHY-97110HM-PT SESSION BY PT ASST 13 28.000000 1600.4800 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 40 129.250000 9233.6200 71.4400
SPL-92508-GROUP SPL SESSION PER CHILD 1 1.000000 13.8800 13.8800
Subtotal (Total Children Is Unduplicated) 481 2267.750000 119184.3800 52.5562
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Total 5507.000000 255593.1300 46.4124
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Number of Children (Unduplicated) With at Least One Service 1084
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Center 06
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 0 0.000000 0.0000 0.0000
6947 5507.000000 255593.1300 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 6947 5507.000000 255593.1300 0.0000