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: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 990 3400.750000 125827.7500 37.0000
Subtotal (Total Children Is Unduplicated) 990 3400.750000 125827.7500 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 10 5.500000 412.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 12 9.500000 712.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 7 4.500000 337.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 16 16.500000 1237.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 36 36.500000 2025.7500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 71 42.000000 3150.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 15 11.500000 862.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 83 55.000000 4125.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 212 197.000000 10933.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 69 53.000000 3975.0000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 10 10.000000 405.0000 40.5000
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 1 1.000000 57.2700 57.2700
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 5 5.000000 110.7000 22.1400
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 1 1.000000 51.0500 51.0500
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 4 5.000000 255.2500 51.0500
PSTH-97001-EVAL BY LICENSED PT, INITIAL 1 1.000000 51.0500 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 1 1.000000 51.0500 51.0500
Subtotal (Total Children Is Unduplicated) 269 455.000000 28753.1200 63.1937
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 851 7356.000000 367800.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 5 17.000000 1214.4800 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 1 1.000000 57.2000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 9 66.000000 4715.0400 71.4400
PHY-97110HM-PT SESSION BY PT ASST 5 42.000000 2400.7200 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 7 36.500000 2607.5600 71.4400
Subtotal (Total Children Is Unduplicated) 867 7518.500000 378795.0000 50.3817
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Total 11374.250000 533375.8700 46.8933
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Number of Children (Unduplicated) With at Least One Service 1277
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Center 04
Flag Claims Units Chgs Paid
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R 53 66.750000 2469.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 557 746.750000 28346.2500 0.0000
P 1937 2591.500000 102567.8000 102525.4500
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 2109 7514.000000 378460.4800 0.0000
T 0 0.000000 0.0000 0.0000
388 449.500000 21129.4200 0.0000
Other 3 5.750000 402.1700 0.0000
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Total 5047 11374.250000 533375.8700 102525.4500