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:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 835 1496.000000 55352.0000 37.0000
Subtotal (Total Children Is Unduplicated) 835 1496.000000 55352.0000 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 2.000000 150.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 1.000000 75.0000 75.0000
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 50 86.500000 6487.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 25 40.000000 3000.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 32 53.500000 4012.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 24 38.500000 2136.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 13 20.000000 1500.0000 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) 85 250.000000 17831.6000 71.3264
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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 1989.500000 87207.8000 43.8340
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Number of Children (Unduplicated) With at Least One Service 847
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Center 03
Flag Claims Units Chgs Paid
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R 31 12.500000 475.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 181 197.750000 12338.3300 111.0000
P 2691 1675.250000 67705.2500 67785.9920
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
39 17.750000 669.7500 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 3029 1989.500000 87207.8000 67896.9920