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
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 831 740.250000 27389.2500 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 1615 5919.750000 219030.7500 37.0000
Subtotal (Total Children Is Unduplicated) 1669 6660.000000 246420.0000 37.0000
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Screening, Eval, and Assessment,Class #02
EVAL-96111-DEVELOPMENTAL EVALUATION 57 57.250000 2862.5000 50.0000
EXIT-EXIT-EXIT ASSESSMENT 104 107.000000 5350.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 23 17.000000 1275.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 27 24.000000 1800.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 11 6.500000 487.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 46 46.500000 3803.2500 81.7903
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 42 46.000000 2553.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 143 113.500000 8512.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 138 116.500000 8737.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 83 52.000000 3900.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 310 366.000000 20313.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 156 140.000000 11320.2600 80.8590
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 64 64.000000 6281.0000 98.1406
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 1 1.000000 57.2700 57.2700
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 15 15.000000 673.8200 44.9213
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 1 1.000000 51.0500 51.0500
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 20 20.000000 1000.1800 50.0090
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 5 5.000000 255.2500 51.0500
PSTH-97001-EVAL BY LICENSED PT, INITIAL 20 20.000000 1021.0000 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 45 46.000000 2348.3000 51.0500
Subtotal (Total Children Is Unduplicated) 573 1264.250000 82602.3800 65.3371
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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
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 68 5223.000000 130575.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1052 9036.000000 451800.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 1026 8867.000000 88670.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 61 332.000000 23268.0800 70.0846
OCCT-97530HM-OT SESSION BY OT ASST 10 62.000000 3496.4000 56.3935
PHY-97110-PT SESSION BY LICENSED PT 58 223.500000 15966.8400 71.4400
PHY-97110HM-PT SESSION BY PT ASST 25 244.500000 13964.0800 57.1128
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 52 229.750000 16413.3400 71.4400
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 4 23.000000 1315.6000 57.2000
Subtotal (Total Children Is Unduplicated) 1209 24316.25000 749244.3400 30.8125
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Total 32240.500000 1078266.7200 33.4445
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Number of Children (Unduplicated) With at Least One Service 1868
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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 65 102.500000 3792.5000 0.0000
P 6382 15472.750000 377899.6400 378392.0400
D 51 86.000000 3103.5000 40.0000
S 3 9.250000 407.2500 0.0000
H 2111 7808.500000 392068.6700 947.2000
T 1 1.500000 55.5000 0.0000
3748 8644.000000 293263.4000 0.0000
Other 47 108.500000 7398.7600 2200.4400
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Total 12411 32240.500000 1078266.7200 381579.6800