CMS/EIP Fiscal Report Center: 52
Services beginning 10/01/2016 ending 12/31/2016 Date of Report:02/04/2017 Page: 1
List order: No List
Payclass Filters:MED
Bill Flag Filter:RBPU
Eligibility Filter:All
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 555 1412.000000 52133.0000 36.9214
Subtotal (Total Children Is Unduplicated) 555 1412.000000 52133.0000 36.9214
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 4 8.000000 600.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 8 16.000000 1200.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 2 4.000000 300.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 16 31.500000 1748.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 62 123.500000 9262.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 50 100.000000 7500.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 10 20.000000 1500.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 109 213.000000 11655.0000 54.7183
SCREEN-T1023-SCREENING 25 25.000000 1250.0000 50.0000
SPCH-92524-BEHAV & QUAL ANALYSIS OF
VOICE AND RES 1 1.000000 51.0500 51.0500
Subtotal (Total Children Is Unduplicated) 151 542.000000 35066.8000 64.6989
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 108 521.500000 26075.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 5 12.000000 857.2800 71.4400
PHY-97110-PT SESSION BY LICENSED PT 4 9.000000 642.9600 71.4400
PHY-97110HM-PT SESSION BY PT ASST 4 20.000000 1143.2000 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 25 72.500000 5179.4000 71.4400
Subtotal (Total Children Is Unduplicated) 137 635.000000 33897.8400 53.3824
-----------------------------------------------------------------------------------------------------------------------
Total 2589.000000 121097.6400 46.7739
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 585
-----------------------------------------------------------------------------------------------------------------------
Center 52
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 9 12.000000 750.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 949 1010.500000 52482.5000 175.7500
P 1791 1566.500000 67865.1400 66646.1200
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
0 0.000000 0.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 2749 2589.000000 121097.6400 66821.8700