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:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 3 2.000000 25.0000 12.5000
TCM-T1017TL-TARGETED CASE MANAGEMENT 7 7.750000 286.7500 37.0000
Subtotal (Total Children Is Unduplicated) 9 9.750000 311.7500 31.9744
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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 40 79.000000 5412.2200 68.5091
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 14 28.000000 2000.0000 71.4286
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 6 12.000000 900.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 63 123.500000 6693.4400 54.1979
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) 91 274.500000 16684.9400 60.7830
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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
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Total 937.250000 56333.4000 60.1050
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Number of Children (Unduplicated) With at Least One Service 194
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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 20 30.000000 893.4500 893.4500
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 193 220.250000 14461.1500 9205.3100
531 687.000000 40978.8000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 744 937.250000 56333.4000 10098.7600