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:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 1200 4473.750000 165528.7500 37.0000
Subtotal (Total Children Is Unduplicated) 1200 4473.750000 165528.7500 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 19 15.500000 1162.5000 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 30 28.500000 1581.7500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 112 86.500000 6487.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 101 84.000000 6300.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 62 35.500000 2662.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 235 218.000000 12099.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 68 57.500000 4312.5000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 33 33.000000 1336.5000 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) 319 648.000000 41154.1200 63.5094
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 872 7454.000000 372700.0000 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) 922 8061.750000 414176.0600 51.3755
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Total 13183.500000 620858.9300 47.0936
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Number of Children (Unduplicated) With at Least One Service 1383
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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 3369 4763.750000 189685.8900 190178.4500
D 0 0.000000 0.0000 0.0000
S 3 9.250000 407.2500 0.0000
H 2093 7747.500000 391364.2700 357.2000
T 1 1.500000 55.5000 0.0000
350 551.500000 35276.0200 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 5884 13183.500000 620858.9300 190535.6500