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
Agency Filter:EIP DEI DEIP
Payclass Filters:MED
Eligibility Filter:Part C (excluding not eligible)
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 1544 4299.000000 157291.5000 36.5879
Subtotal (Total Children Is Unduplicated) 1544 4299.000000 157291.5000 36.5879
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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 7 12.500000 937.5000 75.0000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 17 24.000000 1800.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 31 41.500000 3112.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 19 30.500000 2287.5000 75.0000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 12 18.000000 1350.0000 75.0000
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 1 1.000000 51.0500 51.0500
Subtotal (Total Children Is Unduplicated) 85 143.000000 10701.0500 74.8325
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 11 27.000000 1350.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 5 10.000000 714.4000 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 12.500000 893.0000 71.4400
Subtotal (Total Children Is Unduplicated) 33 83.500000 5386.3600 64.5073
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Total 4525.500000 173378.9100 38.3115
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Number of Children (Unduplicated) With at Least One Service 1548
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Center 01
Flag Claims Units Chgs Paid
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R 7 2.000000 47.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 6411 4320.750000 165477.6200 0.0000
P 0 0.000000 0.0000 0.0000
D 1 0.250000 9.2500 0.0000
S 162 143.250000 5532.2500 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
97 53.500000 2100.0400 0.0000
Other 7 5.750000 212.7500 0.0000
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Total 6685 4525.500000 173378.9100 0.0000