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:TPIN
Eligibility Filter:Part C (excluding not eligible)
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 2 0.750000 25.0000 33.3333
TCM-T1017TL-TARGETED CASE MANAGEMENT 4 5.500000 203.5000 37.0000
Subtotal (Total Children Is Unduplicated) 6 6.250000 228.5000 36.5600
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 1 1.000000 8.7500 8.7500
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 2 4.000000 300.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 2 3.000000 166.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 25 49.500000 3298.2600 66.6315
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 12 24.000000 1700.0000 70.8333
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 4 8.000000 600.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 44 88.500000 4807.2300 54.3190
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 6 8.000000 408.4000 51.0500
SCREEN-T1023-SCREENING 8 8.000000 400.0000 50.0000
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 7 7.000000 344.5800 49.2257
SPCH-92524-BEHAV & QUAL ANALYSIS OF
VOICE AND RES 1 1.000000 51.0500 51.0500
Subtotal (Total Children Is Unduplicated) 68 202.000000 12084.7700 59.8256
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 2 2.250000 112.5000 50.0000
CONIF-CONIF-CONSULT, FACE TO FACE 2 3.000000 150.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 63 230.000000 11417.5000 49.6413
OCCT-97530-OT SESSION BY LICENSED OT 19 91.250000 6352.4400 69.6158
PHY-97110-PT SESSION BY LICENSED PT 16 83.750000 5866.6000 70.0490
PHY-97110HM-PT SESSION BY PT ASST 2 4.000000 228.6400 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 51 234.750000 15153.5100 64.5517
SPL-92508-GROUP SPL SESSION PER CHILD 1 4.000000 55.5200 13.8800
Subtotal (Total Children Is Unduplicated) 133 653.000000 39336.7100 60.2400
-----------------------------------------------------------------------------------------------------------------------
Total 861.250000 51649.9800 59.9709
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 170
-----------------------------------------------------------------------------------------------------------------------
Center 52
Flag Claims Units Chgs Paid
---------------------------------------------------------
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 19 28.000000 838.7400 838.7400
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 177 189.250000 12399.4000 7439.0400
505 644.000000 38411.8400 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 701 861.250000 51649.9800 8277.7800