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
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 555 1412.500000 52151.5000 36.9214
Subtotal (Total Children Is Unduplicated) 555 1412.500000 52151.5000 36.9214
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 8 15.500000 1162.5000 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 3 6.000000 450.0000 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 94 186.500000 13987.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 51 102.000000 7650.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 17 34.000000 2550.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 109 213.000000 11655.0000 54.7183
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 5 10.000000 750.0000 75.0000
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 3 3.000000 153.1500 51.0500
SCREEN-T1023-SCREENING 25 25.000000 1250.0000 50.0000
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 3 3.000000 153.1500 51.0500
SPCH-92524-BEHAV & QUAL ANALYSIS OF
VOICE AND RES 1 1.000000 51.0500 51.0500
Subtotal (Total Children Is Unduplicated) 157 646.500000 42760.6000 66.1417
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 236 1261.250000 63062.5000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 29 107.250000 7661.9400 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 5 28.000000 1601.6000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 23 79.750000 5697.3400 71.4400
PHY-97110HM-PT SESSION BY PT ASST 4 34.000000 1943.4400 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 102 478.500000 34184.0400 71.4400
Subtotal (Total Children Is Unduplicated) 344 1988.750000 114150.8600 57.3983
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Total 4047.750000 209062.9600 51.6492
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Number of Children (Unduplicated) With at Least One Service 617
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Center 52
Flag Claims Units Chgs Paid
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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 20 18.000000 1264.4800 0.0000
S 43 49.000000 2750.0000 0.0000
H 49 43.250000 2980.8600 0.0000
T 1 2.000000 142.8800 142.8800
650 1346.500000 80827.1000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 3512 4047.750000 209062.9600 66964.7500