CMS/EIP Fiscal Report Center: 53
Services beginning 01/01/2017 ending 03/31/2017 Date of Report:05/05/2017 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
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 2 2.000000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 12 25.500000 943.5000 37.0000
Subtotal (Total Children Is Unduplicated) 14 27.500000 943.5000 34.3091
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Screening, Eval, and Assessment,Class #02
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 2 2.000000 50.6200 25.3100
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 3 5.500000 412.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 4 7.000000 525.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 4 7.500000 416.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 4 7.000000 525.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 3 4.500000 337.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 25 40.500000 2247.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 26 43.418800 3256.4100 75.0000
Subtotal (Total Children Is Unduplicated) 43 119.418800 7921.0300 66.3298
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EI Services,Class #03
COUN-H2019HR-INDIVIDUAL/FAMILY THERAPY 1 1.000000 73.3200 73.3200
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 1 3.000000 75.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 125 656.308800 32832.9400 50.0267
Subtotal (Total Children Is Unduplicated) 125 660.308800 32981.2600 49.9482
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Total 807.227600 41845.7900 51.8389
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Number of Children (Unduplicated) With at Least One Service 155
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Center 53
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 29 29.675000 1410.2500 1845.2500
D 3 3.000000 150.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 4 5.000000 300.0000 300.0000
711 752.302600 39126.2900 637.5000
Other 18 17.250000 859.2500 0.0000
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Total 765 807.227600 41845.7900 2782.7500