CMS/EIP Fiscal Report Center: 04
Services beginning 10/01/2015 ending 12/31/2015 Date of Report:02/13/2016 Page: 1
List order: No List
Payclass Filters:GR
Eligibility Filter:Part C (excluding not eligible)
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
CASE-CASE-NON-TCM CASE MANAGEMENT 634 563.500000 20849.5000 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 514 1752.000000 64824.0000 37.0000
Subtotal (Total Children Is Unduplicated) 927 2315.500000 85673.5000 37.0000
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Screening, Eval, and Assessment,Class #02
EVAL-96111-DEVELOPMENTAL EVALUATION 55 52.000000 2575.0000 49.5192
EXIT-EXIT-EXIT ASSESSMENT 92 95.250000 4762.5000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 2 1.000000 75.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 5 4.000000 300.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 3 2.000000 150.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 4 2.500000 187.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 20 14.500000 804.7500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 28 15.500000 1162.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 7 5.000000 375.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 36 25.000000 1875.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 162 127.500000 7076.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 32 25.500000 1912.5000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 42 42.000000 1701.0000 40.5000
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 2 2.000000 114.5400 57.2700
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 9 9.000000 199.2600 22.1400
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 1 1.000000 51.0500 51.0500
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 4 4.000000 204.2000 51.0500
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 3 3.000000 153.1500 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 10 11.000000 561.5500 51.0500
Subtotal (Total Children Is Unduplicated) 388 444.750000 24393.9000 54.8486
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 13 17.500000 875.0000 50.0000
CONIF-CONIF-CONSULT, FACE TO FACE 3 3.000000 150.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 200 1675.000000 83750.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 1006 8817.000000 88170.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 12 85.000000 5568.5300 65.5121
OCCT-97530HM-OT SESSION BY OT ASST 4 19.250000 1077.2300 55.9600
PHY-97110-PT SESSION BY LICENSED PT 5 26.500000 1893.1600 71.4400
PHY-97110HM-PT SESSION BY PT ASST 8 56.500000 3229.5400 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 14 90.000000 6429.6000 71.4400
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 3 3.000000 171.6000 57.2000
Subtotal (Total Children Is Unduplicated) 1044 10792.75000 191314.6600 17.7262
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Total 13553.000000 301382.0600 22.2373
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Number of Children (Unduplicated) With at Least One Service 1507
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Center 04
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 3092 10784.750000 190789.9800 190789.9800
D 28 43.250000 1656.7500 0.0000
S 0 0.000000 0.0000 0.0000
H 4 6.500000 421.4800 321.4800
T 0 0.000000 0.0000 0.0000
2802 2705.000000 107798.0500 0.0000
Other 7 13.500000 715.8000 322.8800
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Total 5933 13553.000000 301382.0600 191434.3400