CMS/EIP Fiscal Report Center: 10
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 1966 5819.000000 215264.7500 36.9934
Subtotal (Total Children Is Unduplicated) 1966 5819.000000 215264.7500 36.9934
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 5 9.000000 675.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 2 4.000000 300.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 3 5.500000 412.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 2 3.500000 194.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 198 346.500000 25987.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 85 144.000000 10800.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 68 112.000000 8400.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 208 356.000000 19758.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 76 106.500000 7987.5000 75.0000
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 1 1.000000 51.0500 51.0500
PSTH-97001-EVAL BY LICENSED PT, INITIAL 1 1.000000 51.0500 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 5 5.000000 255.2500 51.0500
SPCH-92524-BEHAV & QUAL ANALYSIS OF
VOICE AND RES 1 1.000000 51.0500 51.0500
Subtotal (Total Children Is Unduplicated) 319 1095.000000 74923.1500 68.4230
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 991 8876.750000 443837.5000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 34 233.500000 16681.2400 71.4400
PHY-97110-PT SESSION BY LICENSED PT 35 276.000000 19717.4400 71.4400
PHY-97110HM-PT SESSION BY PT ASST 2 5.500000 314.3800 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 32 176.500000 12609.1600 71.4400
SPL-92508-GROUP SPL SESSION PER CHILD 1 3.000000 41.6400 13.8800
Subtotal (Total Children Is Unduplicated) 1039 9571.250000 493201.3600 51.5295
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Total 16485.250000 783389.2600 47.5206
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Number of Children (Unduplicated) With at Least One Service 2109
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Center 10
Flag Claims Units Chgs Paid
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R 77 47.250000 1748.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 9325 6685.500000 281593.2500 0.0000
P 0 0.000000 0.0000 0.0000
D 0 0.000000 0.0000 0.0000
S 189 151.000000 5587.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
2881 9601.250000 494451.5100 0.0000
Other 1 0.250000 9.2500 0.0000
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Total 12473 16485.250000 783389.2600 0.0000