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:EIP DEI DEIP
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 488 1198.750000 44159.5000 36.8380
Subtotal (Total Children Is Unduplicated) 488 1198.750000 44159.5000 36.8380
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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 53 106.000000 7950.0000 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 18 36.000000 2700.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 111 214.000000 11877.0000 55.5000
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 2 4.000000 204.2000 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 2 2.000000 102.1000 51.0500
Subtotal (Total Children Is Unduplicated) 142 497.000000 32378.3500 65.1476
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 123 574.500000 28725.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 5 33.000000 2357.5200 71.4400
PHY-97110-PT SESSION BY LICENSED PT 7 16.500000 1165.8100 70.6552
PHY-97110HM-PT SESSION BY PT ASST 4 18.500000 1057.4600 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 28 139.000000 9559.7300 68.7750
Subtotal (Total Children Is Unduplicated) 161 781.500000 42865.5200 54.8503
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Total 2477.250000 119403.3700 48.2000
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Number of Children (Unduplicated) With at Least One Service 524
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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 77 69.750000 4891.1500 2710.0000
156 147.500000 9777.9700 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 2685 2477.250000 119403.3700 40544.0000