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:TPIN
Eligibility Filter:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 1 1.000000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 7 16.000000 592.0000 37.0000
Subtotal (Total Children Is Unduplicated) 8 17.000000 592.0000 34.8235
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Screening, Eval, and Assessment,Class #02
EXIT-EXIT-EXIT ASSESSMENT 1 2.000000 100.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 2.000000 150.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 1.500000 112.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 2.000000 150.0000 75.0000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 18 30.500000 2287.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 6 9.000000 675.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 4 6.000000 450.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 5 5.500000 305.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 9 11.000000 825.0000 75.0000
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 2 2.000000 102.1000 51.0500
Subtotal (Total Children Is Unduplicated) 42 71.500000 5157.3500 72.1308
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EI Services,Class #03
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 2 1.250000 62.5000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 60 284.000000 14225.0000 50.0880
OCCT-97530-OT SESSION BY LICENSED OT 3 14.000000 1000.1600 71.4400
PHY-97110-PT SESSION BY LICENSED PT 4 10.950000 786.1500 71.7945
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 7 17.000000 1214.4800 71.4400
TRAV-TRAVS-Travel by mile 21 820.000000 365.0200 0.4451
Subtotal (Total Children Is Unduplicated) 95 1147.200000 17653.3100 15.3882
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Total 1235.700000 23402.6600 18.9388
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Number of Children (Unduplicated) With at Least One Service 132
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Center 54
Flag Claims Units Chgs Paid
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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 1 1.000000 50.0000 50.0000
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
454 1234.700000 23352.6600 3500.5200
Other 0 0.000000 0.0000 0.0000
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Total 455 1235.700000 23402.6600 3550.5200