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
Eligibility Filter:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
CASE-CASE-NON-TCM CASE MANAGEMENT 674 606.750000 22449.7500 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 1480 5546.500000 205220.5000 37.0000
Subtotal (Total Children Is Unduplicated) 1529 6153.250000 227670.2500 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 12 6.500000 487.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 18 14.500000 1087.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 12 8.000000 600.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 28 27.000000 2677.5000 99.1667
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 49 54.000000 2997.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 123 71.000000 5325.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 25 18.500000 1387.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 138 91.000000 6825.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 336 382.000000 21201.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 162 151.000000 15892.5000 105.2483
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 76 76.000000 7341.5000 96.5987
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 4 4.000000 678.8100 169.7025
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 15 15.000000 589.9600 39.3307
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 1 1.000000 51.0500 51.0500
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 6 6.000000 306.3000 51.0500
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 7 8.000000 408.4000 51.0500
PSTH-97001-EVAL BY LICENSED PT, INITIAL 5 6.000000 306.3000 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 14 15.000000 765.7500 51.0500
Subtotal (Total Children Is Unduplicated) 571 1101.750000 76266.0700 69.2227
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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
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 11 137.000000 3425.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1045 9151.000000 457550.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 1006 8817.000000 88170.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 19 111.500000 7461.6900 66.9210
OCCT-97530HM-OT SESSION BY OT ASST 6 27.250000 1534.8300 56.3240
PHY-97110-PT SESSION BY LICENSED PT 23 133.500000 9537.2400 71.4400
PHY-97110HM-PT SESSION BY PT ASST 15 119.500000 6830.6200 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 30 150.500000 10751.7200 71.4400
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 3 3.000000 171.6000 57.2000
SPL-92508-GROUP SPL SESSION PER CHILD 1 6.000000 83.2800 13.8800
Subtotal (Total Children Is Unduplicated) 1110 18676.75000 586540.9800 31.4049
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Total 25931.750000 890477.3000 34.3393
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Number of Children (Unduplicated) With at Least One Service 1772
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Center 04
Flag Claims Units Chgs Paid
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R 54 67.000000 2479.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 581 793.750000 30122.7500 0.0000
P 5161 13553.250000 308830.0300 306627.9300
D 29 47.750000 1823.2500 0.0000
S 0 0.000000 0.0000 0.0000
H 2114 7523.500000 379053.4400 321.4800
T 0 0.000000 0.0000 0.0000
3568 3829.750000 160482.9600 43.1800
Other 46 116.750000 7685.8700 874.0100
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Total 11553 25931.750000 890477.3000 307866.6000