CMS/EIP Fiscal Report Center: 02
Services beginning 10/01/2015 ending 12/31/2015 Date of Report:02/13/2016 Page: 1
List order: No List
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 376 671.750000 24854.7500 37.0000
Subtotal (Total Children Is Unduplicated) 376 671.750000 24854.7500 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 17 33.000000 2400.0000 72.7273
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 3 6.000000 375.0000 62.5000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 30 57.000000 3163.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 4 7.000000 525.0000 75.0000
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 1 1.000000 51.0500 51.0500
PSTH-97001-EVAL BY LICENSED PT, INITIAL 1 1.000000 51.0500 51.0500
SCREEN-T1023-SCREENING 4 4.000000 200.0000 50.0000
Subtotal (Total Children Is Unduplicated) 37 109.000000 6765.6000 62.0697
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 48 231.250000 11562.5000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 2 8.000000 571.5200 71.4400
PHY-97110-PT SESSION BY LICENSED PT 2 4.000000 285.7600 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 2 9.000000 642.9600 71.4400
Subtotal (Total Children Is Unduplicated) 52 252.250000 13062.7400 51.7849
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Total 1033.000000 44683.0900 43.2557
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Number of Children (Unduplicated) With at Least One Service 392
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Center 02
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 0 0.000000 0.0000 0.0000
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 23 24.000000 1528.7200 0.0000
43 70.500000 4728.3700 0.0000
Other 1197 938.500000 38426.0000 0.0000
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Total 1263 1033.000000 44683.0900 0.0000