CMS/EIP Fiscal Report Center: 54
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 963 2725.500000 99030.5000 36.3348
Subtotal (Total Children Is Unduplicated) 963 2725.500000 99030.5000 36.3348
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 6 9.500000 712.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 3 2.500000 187.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 5 7.500000 562.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 6 8.500000 471.7500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 108 177.500000 13312.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 33 43.500000 3262.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 13 17.500000 1312.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 178 277.000000 15336.5000 55.3664
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 78 116.500000 8737.5000 75.0000
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 1 1.000000 51.0500 51.0500
PSTH-97001-EVAL BY LICENSED PT, INITIAL 3 3.000000 153.1500 51.0500
SCREEN-T1023-SCREENING 3 3.000000 150.0000 50.0000
Subtotal (Total Children Is Unduplicated) 237 667.000000 44249.9500 66.3418
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EI Services,Class #03
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 1 1.000000 25.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 590 3698.750000 184763.5000 49.9530
PHY-97110-PT SESSION BY LICENSED PT 14 69.000000 4929.3600 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 7 31.000000 2214.6400 71.4400
Subtotal (Total Children Is Unduplicated) 599 3799.750000 191932.5000 50.5119
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Total 7192.250000 335212.9500 46.6075
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Number of Children (Unduplicated) With at Least One Service 1061
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Center 54
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 4796 4202.250000 184439.2500 0.0000
P 1 2.000000 74.0000 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 2 2.000000 87.0000 0.0000
3007 2985.250000 150584.9500 0.0000
Other 1 0.750000 27.7500 0.0000
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Total 7807 7192.250000 335212.9500 0.0000