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:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 1074 3235.500000 119621.0000 36.9714
Subtotal (Total Children Is Unduplicated) 1074 3235.500000 119621.0000 36.9714
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 18 31.000000 2325.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 13 19.500000 1462.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 3 4.000000 300.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 13 21.000000 1575.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 24 38.000000 2109.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 134 218.500000 16350.0000 74.8284
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 80 122.500000 9187.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 13 17.500000 1312.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 165 270.500000 14957.2500 55.2948
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 66 108.000000 8100.0000 75.0000
PSTH-97001-EVAL BY LICENSED PT, INITIAL 1 1.000000 51.0500 51.0500
SCREEN-T1023-SCREENING 7 7.000000 350.0000 50.0000
Subtotal (Total Children Is Unduplicated) 298 858.500000 58079.8000 67.6527
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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 649 3396.250000 169747.5000 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) 657 3478.610000 175776.9900 50.5308
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Total 7572.610000 353477.7900 46.6785
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Number of Children (Unduplicated) With at Least One Service 1128
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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 5199 4305.500000 185784.0000 50.0000
P 721 745.000000 39849.5000 39865.2500
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
2503 2517.110000 127659.2900 89309.2100
Other 4 2.750000 101.7500 0.0000
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Total 8431 7572.610000 353477.7900 129224.4600