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: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 563 1980.500000 73278.5000 37.0000
Subtotal (Total Children Is Unduplicated) 994 2587.250000 95728.2500 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 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 4 3.000000 225.0000 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 21 15.000000 832.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 34 18.500000 1387.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 10 7.000000 525.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 40 28.000000 2100.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 189 150.000000 8325.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 38 30.500000 2287.5000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 46 46.000000 1863.0000 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 12 13.000000 663.6500 51.0500
Subtotal (Total Children Is Unduplicated) 426 487.750000 26984.5000 55.3244
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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 13867.750000 314027.4100 22.6444
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Number of Children (Unduplicated) With at Least One Service 1580
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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 29 47.750000 1823.2500 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
3036 3015.250000 120276.9000 0.0000
Other 7 13.500000 715.8000 322.8800
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Total 6168 13867.750000 314027.4100 191434.3400