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:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 546 1416.000000 52188.5000 36.8563
Subtotal (Total Children Is Unduplicated) 546 1416.000000 52188.5000 36.8563
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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 116 228.500000 17137.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 59 118.000000 8850.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 28 56.000000 4200.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 150 284.500000 15789.7500 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) 196 731.000000 48338.0500 66.1259
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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 3813.750000 195176.7700 51.1771
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Number of Children (Unduplicated) With at Least One Service 616
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Center 52
Flag Claims Units Chgs Paid
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R 28 52.500000 3918.5000 1050.0000
U 0 0.000000 0.0000 0.0000
B 1826 1802.500000 89044.2500 15060.0000
P 890 741.250000 27388.7500 27386.2500
D 0 0.000000 0.0000 0.0000
S 1 2.000000 150.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 78 70.750000 4962.5900 2744.5000
656 1144.750000 69712.6800 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 3479 3813.750000 195176.7700 46240.7500