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: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 8 2.500000 92.5000 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 1 1.000000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 38 77.750000 2876.7500 37.0000
Subtotal (Total Children Is Unduplicated) 39 81.250000 2969.2500 36.5446
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
EVAL-96111-DEVELOPMENTAL EVALUATION 1 1.000000 25.0000 25.0000
EXIT-EXIT-EXIT ASSESSMENT 1 1.000000 50.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 3 6.000000 450.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 2 4.000000 300.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 2.000000 85.0400 42.5200
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 2 4.000000 222.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 46 89.500000 6126.5500 68.4531
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 29 58.000000 3966.7900 68.3929
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 13 24.500000 1622.7600 66.2351
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 73 141.000000 7509.4700 53.2587
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 1 1.000000 51.0500 51.0500
SCREEN-T1023-SCREENING 9 9.000000 450.0000 50.0000
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 4 4.000000 204.2000 51.0500
Subtotal (Total Children Is Unduplicated) 96 345.000000 21062.8600 61.0518
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 1 1.000000 50.0000 50.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 1 0.500000 25.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 54 285.750000 14287.5000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 2 5.000000 50.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 21 74.000000 4816.5000 65.0878
PHY-97110-PT SESSION BY LICENSED PT 14 70.000000 4781.5800 68.3083
PHY-97110HM-PT SESSION BY PT ASST 2 28.500000 1629.0600 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 71 356.750000 22026.2200 61.7413
TRAV-TRAVS-Travel by mile 2 78.000000 34.7200 0.4451
Subtotal (Total Children Is Unduplicated) 136 899.500000 47700.5800 53.0301
-----------------------------------------------------------------------------------------------------------------------
Total 1325.750000 71732.6900 54.1073
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 210
-----------------------------------------------------------------------------------------------------------------------
Center 52
Flag Claims Units Chgs Paid
---------------------------------------------------------
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 110 127.250000 7048.7500 5532.2700
D 144 154.500000 9092.6200 40.0000
S 1 3.000000 214.3200 0.0000
H 97 103.750000 6905.4200 0.0000
T 21 100.750000 1293.4400 860.4300
612 836.500000 47178.1400 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 985 1325.750000 71732.6900 6432.7000