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: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 1 4.250000 157.2500 37.0000
Subtotal (Total Children Is Unduplicated) 1 4.250000 157.2500 37.0000
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 4 4.000000 204.2000 51.0500
PSTH-97001-EVAL BY LICENSED PT, INITIAL 2 2.000000 102.1000 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 15 15.000000 765.7500 51.0500
Subtotal (Total Children Is Unduplicated) 21 21.000000 1072.0500 51.0500
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 5 24.000000 1200.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 16 51.500000 3679.1600 71.4400
PHY-97110-PT SESSION BY LICENSED PT 16 53.500000 3822.0400 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 26 106.655100 7619.4400 71.4400
Subtotal (Total Children Is Unduplicated) 50 235.655100 16320.6400 69.2565
-----------------------------------------------------------------------------------------------------------------------
Total 260.905100 17549.9400 67.2656
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 61
-----------------------------------------------------------------------------------------------------------------------
Center 57
Flag Claims Units Chgs Paid
---------------------------------------------------------
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 0.655100 46.8000 46.8000
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
133 260.250000 17503.1400 17345.8900
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 134 260.905100 17549.9400 17392.6900