CMS/EIP Fiscal Report Center: 04
Services beginning 10/01/2016 ending 12/31/2016 Date of Report:02/04/2017 Page: 1
List order: No List
Payclass Filters:GR
Eligibility Filter:Part C (excluding not eligible)
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
CASE-CASE-NON-TCM CASE MANAGEMENT 757 683.500000 25289.5000 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 401 1313.750000 48608.7500 37.0000
Subtotal (Total Children Is Unduplicated) 962 1997.250000 73898.2500 37.0000
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Screening, Eval, and Assessment,Class #02
EVAL-96111-DEVELOPMENTAL EVALUATION 56 56.500000 2825.0000 50.0000
EXIT-EXIT-EXIT ASSESSMENT 104 107.000000 5350.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 5 4.000000 300.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 8 8.500000 637.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 3 2.500000 187.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 16 11.500000 862.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 20 17.000000 943.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 26 23.500000 1762.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 29 27.000000 2025.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 20 15.500000 1162.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 154 124.000000 6882.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 42 28.000000 2100.0000 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 5 5.000000 234.4300 46.8860
PSTH-97001-EVAL BY LICENSED PT, INITIAL 2 2.000000 102.1000 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 34 35.000000 1786.7500 51.0500
Subtotal (Total Children Is Unduplicated) 390 486.000000 27855.7500 57.3164
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 36 70.500000 3525.0000 50.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 1 1.000000 50.0000 50.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 1 1.000000 50.0000 50.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 1 1.000000 50.0000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 1 2.000000 100.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 183 1507.000000 75350.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 1025 8864.000000 88640.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 11 60.000000 3836.4000 63.9400
OCCT-97530HM-OT SESSION BY OT ASST 6 45.000000 2524.0000 56.0889
PHY-97110-PT SESSION BY LICENSED PT 10 53.500000 3822.0400 71.4400
PHY-97110HM-PT SESSION BY PT ASST 12 120.500000 6876.2400 57.0642
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 8 45.500000 3250.5200 71.4400
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 4 23.000000 1315.6000 57.2000
Subtotal (Total Children Is Unduplicated) 1083 10794.00000 189389.8000 17.5458
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Total 13277.250000 291143.8000 21.9280
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Number of Children (Unduplicated) With at Least One Service 1560
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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 3003 10697.500000 186410.2400 186410.0800
D 48 77.500000 2789.0000 40.0000
S 0 0.000000 0.0000 0.0000
H 17 59.000000 590.0000 590.0000
T 0 0.000000 0.0000 0.0000
2748 2397.250000 98296.5200 0.0000
Other 18 46.000000 3058.0400 1521.7600
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Total 5834 13277.250000 291143.8000 188561.8400