CMS/EIP Fiscal Report Center: 57
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 914 3149.500000 116531.5000 37.0000
Subtotal (Total Children Is Unduplicated) 914 3149.500000 116531.5000 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 5 4.500000 337.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 0.500000 37.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 2 3.000000 225.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 6 6.500000 360.7500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 142 133.000000 9975.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 6 6.000000 450.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 182 193.500000 10739.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 73 84.000000 6300.0000 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 7 7.000000 357.3500 51.0500
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 1 1.000000 51.0500 51.0500
PSTH-97001-EVAL BY LICENSED PT, INITIAL 6 6.000000 306.3000 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 5 5.000000 255.2500 51.0500
Subtotal (Total Children Is Unduplicated) 225 451.000000 29446.0000 65.2905
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 616 4049.000000 202450.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 22 80.750000 5768.7800 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 3 7.500000 429.0000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 14 38.500000 2750.4400 71.4400
PHY-97110HM-PT SESSION BY PT ASST 12 41.000000 2343.5600 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 13 43.750000 3125.5000 71.4400
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 7 11.500000 657.8000 57.2000
Subtotal (Total Children Is Unduplicated) 663 4272.000000 217525.0800 50.9188
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Total 7872.500000 363502.5800 46.1737
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Number of Children (Unduplicated) With at Least One Service 1096
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Center 57
Flag Claims Units Chgs Paid
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R 3 3.000000 111.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 2644 2529.500000 104101.2500 0.0000
P 945 976.250000 36234.2500 35890.0000
D 2 3.500000 129.5000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 1 -2.000000 -100.0000 -100.0000
1293 4361.500000 222998.8300 222694.1700
Other 1 0.750000 27.7500 0.0000
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Total 4889 7872.500000 363502.5800 258484.1700