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
Agency Filter:EXT
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 1 1.000000 37.0000 37.0000
Subtotal (Total Children Is Unduplicated) 1 1.000000 37.0000 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 7 14.000000 1050.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 3 6.000000 333.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 10 19.000000 1425.0000 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) 43 74.000000 4594.7500 62.0912
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 543 4428.000000 221400.0000 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) 675 5349.500000 281850.1000 52.6872
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Total 5424.500000 286481.8500 52.8126
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Number of Children (Unduplicated) With at Least One Service 688
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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 1 1.000000 37.0000 0.0000
P 0 0.000000 0.0000 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 4 8.000000 485.7600 485.7600
1814 5415.500000 285959.0900 285873.2500
Other 0 0.000000 0.0000 0.0000
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Total 1819 5424.500000 286481.8500 286359.0100