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:TPIN
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 4 4.250000 157.2500 37.0000
Subtotal (Total Children Is Unduplicated) 4 4.250000 157.2500 37.0000
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Screening, Eval, and Assessment,Class #02
EVAL-96111-DEVELOPMENTAL EVALUATION 1 2.000000 100.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 3 4.666667 350.0000 75.0000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 32 47.265503 3544.9104 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 16 25.958300 1946.8700 74.9999
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 9 16.908400 1268.1300 75.0000
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 1 1.000000 51.0500 51.0500
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 3 3.000000 153.1500 51.0500
PSTH-97001-EVAL BY LICENSED PT, INITIAL 2 1.489800 76.0500 51.0471
Subtotal (Total Children Is Unduplicated) 48 102.288670 7490.1604 73.2257
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 2 2.000000 130.2000 65.1000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 5 5.000000 250.0000 50.0000
CONIP-CONIP-CONSULT, ITDS PHONE 1 1.000000 25.0000 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 6 7.000000 350.0000 50.0000
CONOP-CONOP-CONSULT, OT, PHONE 1 1.000000 25.0000 25.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 1 1.000000 50.0000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 1 1.000000 50.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 1 1.000000 10.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 29 144.613016 10331.0900 71.4396
OCCT-97530HM-OT SESSION BY OT ASST 24 121.487069 6949.0600 57.2000
PHY-97110-PT SESSION BY LICENSED PT 19 77.316057 5550.4508 71.7891
PHY-97110HM-PT SESSION BY PT ASST 8 28.307920 1618.0800 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 53 234.775493 16772.3588 71.4400
Subtotal (Total Children Is Unduplicated) 110 625.499555 42111.2396 67.3242
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Total 732.038225 49758.6500 67.9727
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Number of Children (Unduplicated) With at Least One Service 150
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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 0 0.000000 0.0000 0.0000
P 0 0.000000 0.0000 0.0000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 16 30.990400 2324.2800 0.0000
T 0 0.000000 0.0000 0.0000
901 701.047825 47434.3700 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 917 732.038225 49758.6500 0.0000