CMS/EIP Fiscal Report Center: 55
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 791 2581.250000 95497.0000 36.9964
Subtotal (Total Children Is Unduplicated) 791 2581.250000 95497.0000 36.9964
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 6 12.000000 900.0000 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 4 7.000000 525.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 2.000000 111.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 154 307.500000 23062.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 43 86.000000 6450.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 54 106.500000 7987.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 25 50.000000 2775.0000 55.5000
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 1 1.000000 51.0500 51.0500
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 4 4.000000 204.2000 51.0500
PSTH-97001-EVAL BY LICENSED PT, INITIAL 3 3.000000 153.1500 51.0500
Subtotal (Total Children Is Unduplicated) 184 583.000000 42519.4000 72.9321
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EI Services,Class #03
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 1 8.000000 200.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 218 1209.500000 60475.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 53 244.500000 17467.0800 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 66 333.500000 19076.2000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 51 214.750000 15341.7400 71.4400
PHY-97110HM-PT SESSION BY PT ASST 31 160.000000 9145.6000 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 123 670.500000 47900.5200 71.4400
SPL-92508-GROUP SPL SESSION PER CHILD 2 9.000000 124.9200 13.8800
Subtotal (Total Children Is Unduplicated) 416 2849.750000 169731.0600 59.5600
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Total 6014.000000 307747.4600 51.1718
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Number of Children (Unduplicated) With at Least One Service 810
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Center 55
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 30 25.500000 943.5000 0.0000
P 3240 3084.000000 128563.2500 128563.2500
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
3069 2904.500000 178240.7100 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 6339 6014.000000 307747.4600 128563.2500