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: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 1113 4415.750000 163382.7500 37.0000
Subtotal (Total Children Is Unduplicated) 1113 4415.750000 163382.7500 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 13 8.500000 637.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 20 16.000000 1200.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 3 1.500000 112.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 20 22.500000 1687.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 38 37.500000 2081.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 49 28.500000 2137.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 36 24.500000 1837.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 95 59.000000 4425.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 275 257.500000 14291.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 115 81.500000 6112.5000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 15 15.000000 607.5000 40.5000
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 1 1.000000 57.2700 57.2700
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 2 2.000000 44.2800 22.1400
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 2 2.000000 102.1000 51.0500
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 11 11.000000 561.5500 51.0500
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 5 5.000000 255.2500 51.0500
PSTH-97001-EVAL BY LICENSED PT, INITIAL 9 9.000000 459.4500 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 5 5.000000 255.2500 51.0500
SPCH-92524-BEHAV & QUAL ANALYSIS OF
VOICE AND RES 8 9.000000 459.4500 51.0500
Subtotal (Total Children Is Unduplicated) 351 596.000000 37324.6000 62.6252
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 887 7888.000000 393567.0000 49.8944
OCCT-97530-OT SESSION BY LICENSED OT 22 166.750000 11912.6200 71.4400
PHY-97110-PT SESSION BY LICENSED PT 15 121.750000 8697.8200 71.4400
PHY-97110HM-PT SESSION BY PT ASST 7 46.000000 2629.3600 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 22 139.500000 9965.8800 71.4400
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 1 3.000000 171.6000 57.2000
Subtotal (Total Children Is Unduplicated) 922 8365.000000 426944.2800 51.0394
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Total 13376.750000 627651.6300 46.9211
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Number of Children (Unduplicated) With at Least One Service 1325
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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 159 214.500000 9057.5000 0.0000
P 3052 4458.250000 173840.6400 173893.7600
D 1 0.750000 27.7500 0.0000
S 2 4.250000 157.2500 0.0000
H 2321 8119.000000 408962.2400 0.0000
T 0 0.000000 0.0000 0.0000
410 579.000000 35555.2000 0.0000
Other 1 1.000000 51.0500 0.0000
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Total 5946 13376.750000 627651.6300 173893.7600