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:TPIN
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 1 0.750000 27.7500 37.0000
Subtotal (Total Children Is Unduplicated) 1 0.750000 27.7500 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 7 18.000000 1350.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 2 2.000000 150.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 2 1.000000 75.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 2 7.500000 562.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 4 9.000000 499.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 136 305.000000 22875.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 43 83.000000 6225.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 32 59.500000 4462.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 97 211.000000 11710.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 48 102.000000 7650.0000 75.0000
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 2 2.000000 88.6500 44.3250
PSTH-97001-EVAL BY LICENSED PT, INITIAL 1 1.000000 51.0500 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 1 1.000000 51.0500 51.0500
Subtotal (Total Children Is Unduplicated) 182 802.000000 55750.7500 69.5147
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 9 90.000000 4500.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 25 92.000000 6452.6400 70.1374
OCCT-97530HM-OT SESSION BY OT ASST 1 1.000000 57.2000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 37 156.500000 10710.0900 68.4351
PHY-97110HM-PT SESSION BY PT ASST 1 2.500000 142.9000 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 22 103.250000 7349.3000 71.1797
SPL-92508-GROUP SPL SESSION PER CHILD 1 4.000000 55.5200 13.8800
Subtotal (Total Children Is Unduplicated) 74 449.250000 29267.6500 65.1478
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Total 1252.000000 85046.1500 67.9282
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Number of Children (Unduplicated) With at Least One Service 245
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Center 10
Flag Claims Units Chgs Paid
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R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 0 0.000000 0.0000 0.0000
P 0 0.000000 0.0000 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
585 1252.000000 85046.1500 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 585 1252.000000 85046.1500 0.0000