CMS/EIP Fiscal Report Center: 54
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:Part C (excluding not eligible)
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 973 2818.750000 104219.7500 36.9737
Subtotal (Total Children Is Unduplicated) 973 2818.750000 104219.7500 36.9737
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 16 27.500000 2062.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 9 13.500000 1012.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 2 2.500000 187.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 10 16.000000 1200.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 20 32.000000 1776.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 88 146.000000 10912.5000 74.7432
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 57 88.500000 6637.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 11 15.500000 1162.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 114 190.000000 10489.5000 55.2079
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 50 85.000000 6375.0000 75.0000
PSTH-97001-EVAL BY LICENSED PT, INITIAL 1 1.000000 51.0500 51.0500
SCREEN-T1023-SCREENING 5 5.000000 250.0000 50.0000
Subtotal (Total Children Is Unduplicated) 211 622.500000 42116.5500 67.6571
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 3 7.360000 764.3700 103.8546
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 2 2.000000 50.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 647 3394.250000 169647.5000 49.9809
OCCT-97530-OT SESSION BY LICENSED OT 6 26.000000 1857.4400 71.4400
PHY-97110-PT SESSION BY LICENSED PT 9 46.000000 3286.2400 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 1 1.000000 71.4400 71.4400
Subtotal (Total Children Is Unduplicated) 655 3476.610000 175676.9900 50.5311
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Total 6917.860000 322013.2900 46.5481
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Number of Children (Unduplicated) With at Least One Service 1026
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Center 54
Flag Claims Units Chgs Paid
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R 3 2.000000 74.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 4712 3815.000000 163983.5000 50.0000
P 672 682.750000 35758.7500 35774.5000
D 0 0.000000 0.0000 0.0000
S 1 0.250000 9.2500 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
2420 2415.110000 122086.0400 85228.7100
Other 4 2.750000 101.7500 0.0000
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Total 7812 6917.860000 322013.2900 121053.2100