CMS/EIP Fiscal Report Center: 01
Services beginning 10/01/2015 ending 12/31/2015 Date of Report:02/13/2016 Page: 1
List order: No List
Payclass Filters:MED
Bill Flag Filter:RBPU
Eligibility Filter:All
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 1569 4338.750000 158521.7500 36.5363
Subtotal (Total Children Is Unduplicated) 1569 4338.750000 158521.7500 36.5363
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 2 4.000000 300.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 5 8.500000 637.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 2 3.000000 225.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 6 10.500000 787.5000 75.0000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 19 27.000000 2025.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 33 45.000000 3375.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 22 34.500000 2587.5000 75.0000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 13 19.000000 1425.0000 75.0000
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 1 1.000000 51.0500 51.0500
Subtotal (Total Children Is Unduplicated) 92 152.500000 11413.5500 74.8430
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 4 15.000000 750.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 4 8.500000 607.2400 71.4400
PHY-97110-PT SESSION BY LICENSED PT 14 34.000000 2428.9600 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 4 11.500000 821.5600 71.4400
Subtotal (Total Children Is Unduplicated) 25 69.000000 4607.7600 66.7791
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Total 4560.250000 174543.0600 38.2749
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Number of Children (Unduplicated) With at Least One Service 1570
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Center 01
Flag Claims Units Chgs Paid
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R 8 3.000000 118.4400 0.0000
U 0 0.000000 0.0000 0.0000
B 6709 4557.000000 174415.3700 0.0000
P 1 0.250000 9.2500 9.2500
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
0 0.000000 0.0000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 6718 4560.250000 174543.0600 9.2500