CMS/EIP Fiscal Report Center: 09
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 993 3411.000000 126133.0000 36.9783
Subtotal (Total Children Is Unduplicated) 993 3411.000000 126133.0000 36.9783
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 10 18.000000 1350.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 5 10.000000 750.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 4 7.000000 388.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 120 185.500000 13770.0000 74.2318
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 65 87.500000 6562.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 47 67.500000 5062.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 128 205.500000 11405.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 76 100.000000 7500.0000 75.0000
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 4 4.000000 204.2000 51.0500
Subtotal (Total Children Is Unduplicated) 219 685.000000 46992.9500 68.6028
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 633 4309.000000 215450.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 30 175.000000 12502.0000 71.4400
PHY-97110-PT SESSION BY LICENSED PT 62 438.000000 31290.7200 71.4400
PHY-97110HM-PT SESSION BY PT ASST 1 3.000000 171.4800 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 67 489.000000 34934.1600 71.4400
SPL-92508-GROUP SPL SESSION PER CHILD 1 1.000000 13.8800 13.8800
Subtotal (Total Children Is Unduplicated) 730 5415.000000 294362.2400 54.3605
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Total 9511.000000 467488.1900 49.1524
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Number of Children (Unduplicated) With at Least One Service 1070
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Center 09
Flag Claims Units Chgs Paid
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R 5 5.000000 198.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 161 184.750000 9966.2500 225.2500
P 4430 4081.000000 171712.3000 282712.0500
D 0 0.000000 0.0000 0.0000
S 1 1.250000 46.2500 46.2500
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
1742 5239.000000 285565.3900 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 6339 9511.000000 467488.1900 282983.5500