CMS/EIP Fiscal Report Center: 57
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: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 823 2944.250000 108937.2500 37.0000
Subtotal (Total Children Is Unduplicated) 823 2944.250000 108937.2500 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 4 4.000000 300.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 2 2.000000 150.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 6 6.000000 333.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 133 126.500000 9487.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 7 14.000000 1050.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 1 1.000000 75.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 135 136.500000 7575.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 65 72.500000 5437.5000 75.0000
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 13 13.000000 663.6500 51.0500
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 1 1.000000 51.0500 51.0500
PSTH-97001-EVAL BY LICENSED PT, INITIAL 4 4.000000 204.2000 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 17 17.000000 867.8500 51.0500
Subtotal (Total Children Is Unduplicated) 203 397.500000 26195.5000 65.9006
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 544 4429.000000 221450.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 68 210.750000 15055.9800 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 36 62.000000 3546.4000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 30 113.000000 8072.7200 71.4400
PHY-97110HM-PT SESSION BY PT ASST 42 156.500000 8945.5400 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 62 220.250000 15734.6600 71.4400
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 55 159.000000 9094.8000 57.2000
Subtotal (Total Children Is Unduplicated) 676 5350.500000 281900.1000 52.6867
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Total 8692.250000 417032.8500 47.9775
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Number of Children (Unduplicated) With at Least One Service 967
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Center 57
Flag Claims Units Chgs Paid
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R 6 6.750000 249.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 3323 3232.500000 128838.2500 0.0000
P 1 1.500000 55.5000 55.5000
D 8 7.750000 343.2500 0.0000
S 0 0.000000 0.0000 0.0000
H 15 18.500000 1023.5000 0.0000
T 4 8.000000 485.7600 485.7600
1816 5417.250000 286036.8400 285923.2500
Other 0 0.000000 0.0000 0.0000
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Total 5173 8692.250000 417032.8500 286464.5100