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
Agency Filter:EXT
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 1 1.000000 37.0000 37.0000
Subtotal (Total Children Is Unduplicated) 1 1.000000 37.0000 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 38 74.000000 5550.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
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 3 3.000000 153.1500 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 6 6.000000 306.3000 51.0500
Subtotal (Total Children Is Unduplicated) 47 87.000000 6309.4500 72.5224
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 90 530.250000 26512.5000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 17 96.000000 6858.2400 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 1 6.250000 357.5000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 1 7.000000 500.0800 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 47 245.750000 17556.3800 71.4400
Subtotal (Total Children Is Unduplicated) 145 885.250000 51784.7000 58.4973
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Total 973.250000 58131.1500 59.7289
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Number of Children (Unduplicated) With at Least One Service 182
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Center 52
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 1 1.000000 71.4400 34.5000
487 972.250000 58059.7100 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 488 973.250000 58131.1500 34.5000