CMS/EIP Fiscal Report Center: 04
Services beginning 01/01/2017 ending 03/31/2017 Date of Report:05/05/2017 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 899 887.750000 32846.7500 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 540 2154.500000 79716.5000 37.0000
Subtotal (Total Children Is Unduplicated) 1146 3042.250000 112563.2500 37.0000
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Screening, Eval, and Assessment,Class #02
EVAL-96111-DEVELOPMENTAL EVALUATION 61 67.500000 3375.0000 50.0000
EXIT-EXIT-EXIT ASSESSMENT 112 123.750000 6187.5000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 8 5.500000 412.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 3 2.000000 150.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 2 1.000000 75.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 12 9.500000 712.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 30 22.500000 1248.7500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 42 33.500000 2512.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 44 37.500000 2812.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 28 17.500000 1312.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 269 201.000000 11155.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 69 51.500000 3862.5000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 42 42.000000 2001.1500 47.6464
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 5 5.000000 119.6400 23.9280
OCTF-97168-OT RE-EVAL EST PLAN CARE 2 2.000000 102.1000 51.0500
OCTH-97165-OT EVAL LOW COMPLEXITY 1 1.000000 51.0500 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 8 8.000000 408.4000 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 6 6.000000 306.3000 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 35 35.000000 1786.7500 51.0500
Subtotal (Total Children Is Unduplicated) 565 671.750000 38592.1400 57.4502
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 23 39.750000 1987.5000 50.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 1 1.000000 50.0000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 3 5.000000 250.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 220 2069.000000 103450.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 1106 10627.00000 106270.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 20 109.000000 7644.0800 70.1292
OCCT-97530HM-OT SESSION BY OT ASST 5 34.000000 1944.8000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 10 54.000000 3536.2800 65.4867
PHY-97110HM-PT SESSION BY PT ASST 9 55.500000 3088.1300 55.6420
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 10 51.000000 3536.2800 69.3388
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 8 38.000000 2173.6000 57.2000
Subtotal (Total Children Is Unduplicated) 1149 13083.25000 233930.6700 17.8802
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Total 16797.250000 385086.0600 22.9255
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Number of Children (Unduplicated) With at Least One Service 1780
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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 3373 13014.750000 231726.6800 231726.6800
D 83 108.250000 4042.7500 0.0000
S 0 0.000000 0.0000 0.0000
H 15 50.500000 975.7200 120.0000
T 0 0.000000 0.0000 0.0000
3921 3579.750000 145785.3400 0.0000
Other 19 44.000000 2555.5700 1595.1800
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Total 7411 16797.250000 385086.0600 233441.8600