CMS/EIP Fiscal Report Center: 04
Services beginning 01/01/2016 ending 03/31/2016 Date of Report:05/12/2016 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 724 620.500000 22958.5000 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 502 1821.500000 67395.5000 37.0000
Subtotal (Total Children Is Unduplicated) 991 2442.000000 90354.0000 37.0000
-----------------------------------------------------------------------------------------------------------------------
Screening, Eval, and Assessment,Class #02
EVAL-96111-DEVELOPMENTAL EVALUATION 69 73.500000 3675.0000 50.0000
EXIT-EXIT-EXIT ASSESSMENT 71 75.000000 3750.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 1.000000 75.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 0.500000 37.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 2 1.500000 112.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 5 4.500000 337.5000 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 25 17.500000 1312.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 7 6.500000 487.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 35 27.000000 2025.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 248 201.500000 11183.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 46 29.500000 2212.5000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 50 50.000000 2025.0000 40.5000
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 9 9.000000 199.2600 22.1400
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 1 2.000000 102.1000 51.0500
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 5 5.000000 255.2500 51.0500
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 2 2.000000 102.1000 51.0500
PSTH-97001-EVAL BY LICENSED PT, INITIAL 7 7.000000 357.3500 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 15 15.000000 765.7500 51.0500
SPCH-92524-BEHAV & QUAL ANALYSIS OF
VOICE AND RES 2 2.000000 102.1000 51.0500
Subtotal (Total Children Is Unduplicated) 453 544.500000 29921.9100 54.9530
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 32 50.500000 2525.0000 50.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 2 3.000000 150.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 189 1654.500000 82725.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 1050 9334.000000 93340.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 14 72.000000 5023.6800 69.7733
OCCT-97530HM-OT SESSION BY OT ASST 2 17.000000 972.4000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 7 25.000000 1786.0000 71.4400
PHY-97110HM-PT SESSION BY PT ASST 12 65.000000 3715.4000 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 9 42.500000 2987.9600 70.3049
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 3 18.500000 1058.2000 57.2000
Subtotal (Total Children Is Unduplicated) 1094 11282.00000 194283.6400 17.2207
-----------------------------------------------------------------------------------------------------------------------
Total 14268.500000 314559.5500 22.0457
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 1580
-----------------------------------------------------------------------------------------------------------------------
Center 04
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 1 4.000000 148.0000 0.0000
P 3312 11248.000000 194465.3000 194465.3000
D 45 65.500000 2423.5000 0.0000
S 0 0.000000 0.0000 0.0000
H 29 41.000000 471.4400 281.4400
T 0 0.000000 0.0000 0.0000
3033 2895.000000 116581.3100 0.0000
Other 9 15.000000 470.0000 410.0000
---------------------------------------------------------
Total 6429 14268.500000 314559.5500 195156.7400