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:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 1065 2803.250000 103536.0000 36.9343
Subtotal (Total Children Is Unduplicated) 1065 2803.250000 103536.0000 36.9343
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 7 12.000000 900.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 3 6.000000 450.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 1.000000 75.0000 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 146 219.000000 16425.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 60 93.500000 7012.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 174 263.000000 14596.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 18 29.000000 2175.0000 75.0000
Subtotal (Total Children Is Unduplicated) 208 636.500000 42355.5000 66.5444
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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 5707.500000 265075.8800 46.4434
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Number of Children (Unduplicated) With at Least One Service 1124
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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
7132 5707.500000 265075.8800 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 7132 5707.500000 265075.8800 0.0000