CMS/EIP Fiscal Report Center: 55
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 730 2043.000000 75591.0000 37.0000
Subtotal (Total Children Is Unduplicated) 730 2043.000000 75591.0000 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 2.000000 150.0000 75.0000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 83 163.392800 12254.4600 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 12 22.845800 1713.4300 74.9998
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 62 123.000000 9225.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 38 75.000000 4162.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 41 82.000000 6150.0000 75.0000
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 1 1.000000 51.0500 51.0500
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 1 1.000000 51.0500 51.0500
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 1 1.000000 51.0500 51.0500
PSTH-97001-EVAL BY LICENSED PT, INITIAL 3 3.000000 153.1500 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 5 5.000000 255.2500 51.0500
Subtotal (Total Children Is Unduplicated) 159 479.238600 34216.9400 71.3985
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 69 384.750000 19237.5000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 56 281.750000 20128.2200 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 28 145.750000 8336.9000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 53 251.470100 17965.0200 71.4400
PHY-97110HM-PT SESSION BY PT ASST 16 71.000000 4058.3600 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 198 1081.000000 77226.6400 71.4400
Subtotal (Total Children Is Unduplicated) 334 2215.720100 146952.6400 66.3227
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Total 4737.958700 256760.5800 54.1922
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Number of Children (Unduplicated) With at Least One Service 790
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Center 55
Flag Claims Units Chgs Paid
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R 1 1.000000 37.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 171 162.750000 6021.7500 18.5000
P 2126 2077.250000 85484.2500 103345.7500
D 2 0.500000 18.5000 0.0000
S 52 28.500000 1054.5000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
2723 2467.958700 164144.5800 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 5075 4737.958700 256760.5800 103364.2500