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:TPIN
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 1 0.500000 18.5000 37.0000
Subtotal (Total Children Is Unduplicated) 1 0.500000 18.5000 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 4 5.000000 375.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 4 5.000000 277.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 4 6.000000 450.0000 75.0000
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 1 1.000000 51.0500 51.0500
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 2 2.000000 102.1000 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 11 11.000000 561.5500 51.0500
Subtotal (Total Children Is Unduplicated) 19 30.000000 1817.2000 60.5733
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EI Services,Class #03
CONIF-CONIF-CONSULT, FACE TO FACE 1 1.000000 50.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 23 131.000000 6550.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 2 6.000000 60.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 4 13.500000 964.4400 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 1 11.000000 629.2000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 22 96.500000 6893.9600 71.4400
PHY-97110HM-PT SESSION BY PT ASST 1 4.000000 228.6400 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 43 266.500000 19038.7600 71.4400
Subtotal (Total Children Is Unduplicated) 90 529.500000 34415.0000 64.9953
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Total 560.000000 36250.7000 64.7334
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Number of Children (Unduplicated) With at Least One Service 102
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Center 57
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 0 0.000000 0.0000 0.0000
D 0 0.000000 0.0000 0.0000
S 1 3.500000 250.0400 250.0400
H 0 0.000000 0.0000 0.0000
T 1 3.000000 30.0000 30.0000
213 553.500000 35970.6600 35110.6600
Other 0 0.000000 0.0000 0.0000
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Total 215 560.000000 36250.7000 35390.7000