CMS/EIP Fiscal Report Center: 09
Services beginning 01/01/2017 ending 03/31/2017 Date of Report:05/05/2017 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 1060 3301.750000 122146.2500 36.9944
Subtotal (Total Children Is Unduplicated) 1060 3301.750000 122146.2500 36.9944
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 8 13.000000 975.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 4 6.500000 487.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 5 8.000000 600.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 8 12.500000 937.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 7 11.500000 638.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 102 149.000000 11095.0000 74.4631
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 103 133.500000 9987.5000 74.8127
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 108 163.000000 12225.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 184 269.000000 14777.0200 54.9332
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 101 140.500000 10512.5000 74.8221
Subtotal (Total Children Is Unduplicated) 303 906.500000 62235.2700 68.6545
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 727 5140.500000 257025.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 48 442.000000 31576.4800 71.4400
PHY-97110-PT SESSION BY LICENSED PT 76 582.000000 41578.0800 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 76 632.000000 45150.0800 71.4400
Subtotal (Total Children Is Unduplicated) 832 6796.500000 375329.6400 55.2240
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Total 11004.750000 559711.1600 50.8609
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Number of Children (Unduplicated) With at Least One Service 1185
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Center 09
Flag Claims Units Chgs Paid
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R 2 3.500000 129.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 229 209.250000 8238.2500 27.7500
P 4077 4080.000000 173697.7700 173697.7700
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
2006 6447.500000 358067.1400 0.0000
Other 183 264.500000 19578.5000 0.0000
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Total 6497 11004.750000 559711.1600 173725.5200