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:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 1027 3566.000000 131942.0000 37.0000
Subtotal (Total Children Is Unduplicated) 1027 3566.000000 131942.0000 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 13 10.500000 787.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 8 5.000000 375.0000 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 38 39.000000 2164.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 89 52.500000 3937.5000 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 98 63.000000 4725.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 252 232.000000 12876.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 79 60.000000 4500.0000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 13 13.000000 526.5000 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) 313 522.500000 32980.8700 63.1213
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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 11607.000000 543717.8700 46.8440
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Number of Children (Unduplicated) With at Least One Service 1331
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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 2033 2736.500000 108769.5500 108727.2000
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
437 490.000000 23483.9200 0.0000
Other 3 5.750000 402.1700 0.0000
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Total 5217 11607.000000 543717.8700 108727.2000