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:TPIN
Eligibility Filter:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
CASE-CASE-NON-TCM CASE MANAGEMENT 1 0.750000 27.7500 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 2 0.500000 18.5000 37.0000
Subtotal (Total Children Is Unduplicated) 3 1.250000 46.2500 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 2 3.500000 262.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 2 3.500000 262.5000 75.0000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 92 138.500000 10387.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 49 76.000000 5700.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 94 151.000000 8325.0000 55.1325
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 17 27.500000 2062.5000 75.0000
Subtotal (Total Children Is Unduplicated) 128 400.000000 27000.0000 67.5000
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 3 13.000000 650.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 13 25.750000 1839.5800 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 3 5.000000 286.0000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 30 65.250000 4661.4600 71.4400
PHY-97110HM-PT SESSION BY PT ASST 1 3.000000 171.4800 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 44 142.500000 10180.2000 71.4400
Subtotal (Total Children Is Unduplicated) 87 254.500000 17788.7200 69.8967
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Total 655.750000 44834.9700 68.3720
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Number of Children (Unduplicated) With at Least One Service 204
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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
645 655.750000 44834.9700 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 645 655.750000 44834.9700 0.0000