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:MED
Eligibility Filter:Part C (excluding not eligible)
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 1139 4140.750000 153207.7500 37.0000
Subtotal (Total Children Is Unduplicated) 1139 4140.750000 153207.7500 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 18 13.000000 975.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 18 15.000000 1125.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 8 4.000000 300.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 23 19.500000 1462.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 29 28.000000 1554.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 81 62.000000 4650.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 80 67.000000 5025.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 54 30.500000 2287.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 184 170.500000 9462.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 56 47.000000 3525.0000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 29 29.000000 1174.5000 40.5000
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 8 8.000000 177.1200 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 13 13.000000 663.6500 51.0500
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 5 5.000000 255.2500 51.0500
PSTH-97001-EVAL BY LICENSED PT, INITIAL 16 16.000000 816.8000 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 10 10.000000 510.5000 51.0500
Subtotal (Total Children Is Unduplicated) 263 538.500000 34015.6200 63.1674
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 871 7451.000000 372550.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 38 240.500000 17181.3200 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 3 12.000000 686.4000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 24 127.250000 9090.7400 71.4400
PHY-97110HM-PT SESSION BY PT ASST 14 124.000000 7087.8400 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 18 104.000000 7429.7600 71.4400
Subtotal (Total Children Is Unduplicated) 921 8058.750000 414026.0600 51.3760
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Total 12738.000000 601249.4300 47.2012
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Number of Children (Unduplicated) With at Least One Service 1320
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Center 04
Flag Claims Units Chgs Paid
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R 3 7.500000 277.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 62 94.750000 3505.7500 0.0000
P 3122 4348.500000 171766.1400 172092.3100
D 0 0.000000 0.0000 0.0000
S 3 9.250000 407.2500 0.0000
H 2091 7744.500000 391214.2700 357.2000
T 1 1.500000 55.5000 0.0000
329 532.000000 34023.0200 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 5611 12738.000000 601249.4300 172449.5100