CMS/EIP Fiscal Report Center: 04
Services beginning 10/01/2017 ending 12/31/2017 Date of Report:02/03/2018 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 821 725.500000 26843.5000 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 1590 6182.250000 228743.2500 37.0000
Subtotal (Total Children Is Unduplicated) 1641 6907.750000 255586.7500 37.0000
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Screening, Eval, and Assessment,Class #02
EVAL-96111-DEVELOPMENTAL EVALUATION 60 67.500000 3375.0000 50.0000
EXIT-EXIT-EXIT ASSESSMENT 120 131.500000 6575.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 19 13.000000 975.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 30 26.000000 1950.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 24 22.500000 1687.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 41 45.500000 2525.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 85 67.500000 5062.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 154 139.500000 10462.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 262 305.500000 16955.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 146 140.000000 11083.5000 79.1679
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 96 96.000000 8684.7700 90.4664
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 2 2.000000 151.4400 75.7200
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 13 13.000000 345.9300 26.6100
MED-99214-OUTPATIENT VISIT, EST, 25 MINS 1 1.000000 41.4600 41.4600
OCTF-97168-OT RE-EVAL EST PLAN CARE 2 2.000000 102.1000 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 35 35.000000 1786.7500 51.0500
PSTF-97164-PT RE-EVAL EST PLAN CARE 7 7.000000 357.3500 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 48 49.000000 2501.4500 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 34 34.000000 1735.7000 51.0500
SPCH-92524-BEHAV & QUAL ANALYSIS OF
VOICE AND RES 1 1.000000 51.0500 51.0500
Subtotal (Total Children Is Unduplicated) 567 1198.500000 76409.5000 63.7543
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 32 53.750000 2687.5000 50.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 4 4.000000 200.0000 50.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 1 1.000000 50.0000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 5 6.000000 300.0000 50.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 69 5628.000000 140700.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1135 11844.00000 592200.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 1143 12206.00000 122060.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 96 613.250000 43774.8600 71.3818
OCCT-97530HM-OT SESSION BY OT ASST 25 194.000000 11096.8000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 71 298.250000 21235.5400 71.2005
PHY-97110HM-PT SESSION BY PT ASST 74 479.750000 27422.5100 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 67 329.500000 23539.4800 71.4400
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 3 25.000000 1430.0000 57.2000
Subtotal (Total Children Is Unduplicated) 1317 31682.50000 986696.6900 31.1433
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Total 39788.750000 1318692.9400 33.1424
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Number of Children (Unduplicated) With at Least One Service 1840
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Center 04
Flag Claims Units Chgs Paid
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R 40 45.750000 1692.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 579 888.000000 34253.0000 0.0000
P 6357 18962.250000 423252.7900 423154.1900
D 44 65.500000 2423.5000 0.0000
S 1 3.000000 111.0000 0.0000
H 2555 10435.500000 530386.2700 170.0000
T 0 0.000000 0.0000 0.0000
3634 9187.250000 313315.1100 0.0000
Other 86 201.500000 13258.5200 396.8100
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Total 13296 39788.750000 1318692.9400 423721.0000