CMS/EIP Fiscal Report Center: 53
Services beginning 07/01/2017 ending 09/30/2017 Date of Report:11/05/2017 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
TCM-T1017TL-TARGETED CASE MANAGEMENT 12 23.750000 878.7500 37.0000
Subtotal (Total Children Is Unduplicated) 12 23.750000 878.7500 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 4 7.500000 562.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 6 11.500000 862.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 3 4.509777 338.2333 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 3 5.500000 305.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 6 12.000000 900.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 2 4.000000 300.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 2 3.500000 262.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 24 38.500000 2131.2500 55.3571
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 23 44.999970 3337.4978 74.1667
Subtotal (Total Children Is Unduplicated) 41 132.009747 8999.7311 68.1747
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EI Services,Class #03
AUD-92593TS-AUDIOLOGY SERVICES (Biaural) 1 1.000000 50.0000 50.0000
COUN-H2019HR-INDIVIDUAL/FAMILY THERAPY 4 6.000000 439.9200 73.3200
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 1 0.250000 0.0000 0.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 3 6.000000 150.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 129 628.250000 31412.5000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 1 1.000000 10.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 2 4.000000 285.7600 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 1 1.000000 57.2000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 4 14.000000 1000.1600 71.4400
PHY-97110HM-PT SESSION BY PT ASST 1 1.000000 57.1600 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 6 20.000000 1428.8000 71.4400
Subtotal (Total Children Is Unduplicated) 134 682.500000 34891.5000 51.1231
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Total 838.259747 44769.9811 53.4082
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Number of Children (Unduplicated) With at Least One Service 152
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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 18 17.906640 821.2202 610.2200
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 13 13.000000 650.0000 650.0000
T 12 13.000000 700.0000 700.0000
700 763.853107 41128.3809 0.0000
Other 30 30.500000 1470.3800 0.0000
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Total 773 838.259747 44769.9811 1960.2200