CMS/EIP Fiscal Report Center: 10
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 1687 4113.500000 152144.0000 36.9865
Subtotal (Total Children Is Unduplicated) 1687 4113.500000 152144.0000 36.9865
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 12 22.500000 1687.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 5 8.000000 600.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 3 4.500000 337.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 14 26.500000 1470.7500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 225 412.500000 30937.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 100 159.000000 11925.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 65 104.500000 7837.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 197 363.000000 20146.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 105 122.000000 9150.0000 75.0000
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 4 4.000000 204.2000 51.0500
Subtotal (Total Children Is Unduplicated) 349 1226.500000 84296.4500 68.7293
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 806 7369.250000 368437.5000 49.9966
OCCT-97530-OT SESSION BY LICENSED OT 39 205.500000 14680.9200 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 1 0.500000 28.6000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 48 218.750000 15627.5000 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 45 270.750000 19342.3800 71.4400
SPL-92508-GROUP SPL SESSION PER CHILD 3 7.750000 107.5700 13.8800
Subtotal (Total Children Is Unduplicated) 868 8072.500000 418224.4700 51.8085
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Total 13412.500000 654664.9200 48.8101
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Number of Children (Unduplicated) With at Least One Service 1873
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Center 10
Flag Claims Units Chgs Paid
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R 270 175.250000 6484.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 6579 5135.000000 228799.2500 0.0000
P 1 0.500000 18.5000 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 0 0.000000 0.0000 0.0000
2535 8101.750000 419362.9200 10.0000
Other 0 0.000000 0.0000 0.0000
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Total 9385 13412.500000 654664.9200 10.0000