CMS/EIP Fiscal Report Center: 09
Services beginning 01/01/2016 ending 03/31/2016 Date of Report:05/12/2016 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 1058 3490.750000 129148.5000 36.9974
Subtotal (Total Children Is Unduplicated) 1058 3490.750000 129148.5000 36.9974
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 20 32.500000 2437.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 4 5.500000 412.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 4 6.000000 450.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 8 12.500000 937.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 14 22.500000 1248.7500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 164 237.000000 17625.0000 74.3671
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 88 113.000000 8450.0000 74.7788
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 64 100.500000 7493.9400 74.5666
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 202 313.500000 17371.5000 55.4115
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 95 119.000000 8825.0000 74.1597
Subtotal (Total Children Is Unduplicated) 329 962.000000 65251.6900 67.8292
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 634 4505.000000 224951.2600 49.9337
OCCT-97530-OT SESSION BY LICENSED OT 31 186.000000 13287.8400 71.4400
PHY-97110-PT SESSION BY LICENSED PT 57 472.000000 33719.6800 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 60 446.000000 31862.2400 71.4400
Subtotal (Total Children Is Unduplicated) 717 5609.000000 303821.0200 54.1667
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Total 10061.750000 498221.2100 49.5164
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Number of Children (Unduplicated) With at Least One Service 1172
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Center 09
Flag Claims Units Chgs Paid
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R 1 2.750000 101.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 98 109.750000 5588.0000 58.5000
P 4514 4535.250000 198449.4400 198449.4400
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 0 0.000000 0.0000 0.0000
1721 5414.000000 294082.0200 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 6334 10061.750000 498221.2100 198507.9400