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
Eligibility Filter:Part C (excluding not eligible)
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
CASE-CASE-NON-TCM CASE MANAGEMENT 818 814.750000 30145.7500 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 1721 7504.000000 277648.0000 37.0000
Subtotal (Total Children Is Unduplicated) 1756 8318.750000 307793.7500 37.0000
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Screening, Eval, and Assessment,Class #02
EVAL-96111-DEVELOPMENTAL EVALUATION 60 67.000000 3350.0000 50.0000
EXIT-EXIT-EXIT ASSESSMENT 112 123.750000 6187.5000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 27 19.000000 1425.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 20 15.000000 1125.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 17 10.000000 750.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 47 59.500000 4462.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 48 50.500000 2802.7500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 168 129.000000 9675.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 154 123.000000 9225.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 94 61.000000 4575.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 355 400.500000 22227.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 259 270.500000 21189.3700 78.3341
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 81 81.000000 7012.8800 86.5788
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 1 1.000000 75.7200 75.7200
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 15 15.000000 880.4400 58.6960
OCTF-97168-OT RE-EVAL EST PLAN CARE 4 4.000000 204.2000 51.0500
OCTH-97165-OT EVAL LOW COMPLEXITY 1 1.000000 51.0500 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 27 28.000000 1429.4000 51.0500
PSTF-97164-PT RE-EVAL EST PLAN CARE 5 5.000000 255.2500 51.0500
PSTH-97161-PT EVAL LOW COMPLEXITY 2 2.000000 102.1000 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 31 31.000000 1582.5500 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 50 50.000000 2552.5000 51.0500
SPCH-92524-BEHAV & QUAL ANALYSIS OF
VOICE AND RES 1 1.000000 51.0500 51.0500
Subtotal (Total Children Is Unduplicated) 718 1547.750000 101192.0100 65.3801
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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
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 65 5424.000000 135600.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1123 10628.00000 531253.0000 49.9862
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 1105 10614.00000 106140.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 68 410.750000 29129.6600 70.9182
OCCT-97530HM-OT SESSION BY OT ASST 14 67.000000 3832.4000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 60 273.000000 19181.6400 70.2624
PHY-97110HM-PT SESSION BY PT ASST 33 285.500000 16234.9300 56.8649
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 64 237.500000 16859.8400 70.9888
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 9 39.000000 2230.8000 57.2000
SPL-92508-GROUP SPL SESSION PER CHILD 10 7.000000 97.1600 13.8800
Subtotal (Total Children Is Unduplicated) 1269 28031.50000 862846.9300 30.7813
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Total 37898.000000 1271832.6900 33.5594
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Number of Children (Unduplicated) With at Least One Service 1902
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Center 04
Flag Claims Units Chgs Paid
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R 1 1.000000 55.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 741 930.750000 41169.0000 0.0000
P 6657 17891.000000 425855.5500 425820.0600
D 83 108.250000 4042.7500 0.0000
S 2 2.000000 74.0000 0.0000
H 2272 8918.500000 449280.2000 348.6400
T 0 0.000000 0.0000 0.0000
4549 9894.500000 341708.4900 0.0000
Other 64 152.000000 9647.2000 3520.3300
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Total 14369 37898.000000 1271832.6900 429689.0300