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:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 1090 3708.750000 137149.7500 36.9800
Subtotal (Total Children Is Unduplicated) 1090 3708.750000 137149.7500 36.9800
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 11 20.000000 1500.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 1.500000 112.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 2.000000 150.0000 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 7 12.500000 693.7500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 165 247.000000 18382.5000 74.4231
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 95 123.000000 9225.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 72 101.500000 7612.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 180 283.000000 15678.7500 55.4019
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 115 147.500000 11062.5000 75.0000
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 4 4.000000 204.2000 51.0500
Subtotal (Total Children Is Unduplicated) 314 952.000000 65371.7000 68.6678
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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 10075.750000 496883.6900 49.3148
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Number of Children (Unduplicated) With at Least One Service 1172
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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 189 225.500000 12554.5000 225.2500
P 4773 4605.000000 198519.5500 309556.8000
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 6710 10075.750000 496883.6900 309828.3000