CMS/EIP Fiscal Report Center: 52
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 489 1199.750000 44196.5000 36.8381
Subtotal (Total Children Is Unduplicated) 489 1199.750000 44196.5000 36.8381
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 4 8.000000 444.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 91 180.000000 13500.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 54 108.000000 8100.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 19 38.000000 2850.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 111 214.000000 11877.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 2.000000 150.0000 75.0000
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 5 7.000000 357.3500 51.0500
PSTH-97001-EVAL BY LICENSED PT, INITIAL 1 1.000000 51.0500 51.0500
SCREEN-T1023-SCREENING 16 16.000000 800.0000 50.0000
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 8 8.000000 408.4000 51.0500
Subtotal (Total Children Is Unduplicated) 154 584.000000 38687.8000 66.2462
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 212 1104.750000 55237.5000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 22 129.000000 9215.7600 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 1 6.250000 357.5000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 8 23.500000 1665.8900 70.8889
PHY-97110HM-PT SESSION BY PT ASST 4 18.500000 1057.4600 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 74 384.750000 27116.1100 70.4772
Subtotal (Total Children Is Unduplicated) 294 1666.750000 94650.2200 56.7873
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Total 3450.500000 177534.5200 51.4518
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Number of Children (Unduplicated) With at Least One Service 559
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Center 52
Flag Claims Units Chgs Paid
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R 22 40.500000 3018.5000 830.0000
U 0 0.000000 0.0000 0.0000
B 1647 1580.000000 78091.7500 13382.5000
P 783 639.500000 23624.0000 23621.5000
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 78 70.750000 4962.5900 2744.5000
643 1119.750000 67837.6800 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 3173 3450.500000 177534.5200 40578.5000