CMS/EIP Fiscal Report Center: 03
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 717 1249.500000 46231.5000 37.0000
Subtotal (Total Children Is Unduplicated) 717 1249.500000 46231.5000 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 1.500000 112.5000 75.0000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 33 60.000000 4500.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 9 16.000000 1200.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 16 27.500000 2062.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 18 30.000000 1665.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 8 11.500000 862.5000 75.0000
PSTH-97001-EVAL BY LICENSED PT, INITIAL 6 6.000000 306.3000 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 1 1.000000 51.0500 51.0500
Subtotal (Total Children Is Unduplicated) 51 153.500000 10759.8500 70.0967
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 46 157.250000 7862.5000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 5 12.000000 857.2800 71.4400
PHY-97110-PT SESSION BY LICENSED PT 13 48.250000 3446.9800 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 6 26.000000 1857.4400 71.4400
Subtotal (Total Children Is Unduplicated) 70 243.500000 14024.2000 57.5943
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Total 1646.500000 71015.5500 43.1312
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Number of Children (Unduplicated) With at Least One Service 724
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Center 03
Flag Claims Units Chgs Paid
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R 30 11.750000 447.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 140 144.000000 8593.3300 74.0000
P 2372 1391.750000 55470.7500 55626.9920
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 87 86.250000 6018.9700 0.0000
T 0 0.000000 0.0000 0.0000
24 12.750000 484.7500 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 2653 1646.500000 71015.5500 55700.9920