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: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 453 1446.000000 53502.0000 37.0000
Subtotal (Total Children Is Unduplicated) 1050 2186.250000 80891.2500 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 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 21 17.500000 971.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 31 27.000000 2025.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 37 32.500000 2437.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 21 16.500000 1237.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 187 148.000000 8214.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 47 31.000000 2325.0000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 17 17.000000 688.5000 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) 430 528.250000 30390.0000 57.5296
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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 1026 8867.000000 88670.0000 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) 1084 10797.00000 189419.8000 17.5437
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Total 13511.500000 300701.0500 22.2552
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Number of Children (Unduplicated) With at Least One Service 1658
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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 3005 10700.500000 186440.2400 186440.0800
D 51 86.000000 3103.5000 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
3003 2620.000000 107509.2700 0.0000
Other 18 46.000000 3058.0400 1521.7600
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Total 6094 13511.500000 300701.0500 188591.8400