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: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 911 815.500000 30173.5000 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 1729 6957.500000 257427.5000 37.0000
Subtotal (Total Children Is Unduplicated) 1783 7773.000000 287601.0000 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 23 16.000000 1200.0000 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 25 23.500000 1762.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 45 48.500000 2691.7500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 127 100.000000 7500.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 200 177.000000 13275.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 363 420.000000 23310.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 207 194.000000 15521.6800 80.0087
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 129 129.000000 12029.9600 93.2555
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) 675 1477.000000 96264.1200 65.1754
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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 1136 11857.00000 592850.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 1144 12219.00000 122190.0000 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) 1318 31708.50000 987476.6900 31.1423
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Total 40958.500000 1371341.8100 33.4813
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Number of Children (Unduplicated) With at Least One Service 1982
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Center 04
Flag Claims Units Chgs Paid
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R 44 61.250000 2266.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 621 960.750000 37359.2500 0.0000
P 6646 19504.000000 445753.8100 445697.0900
D 48 75.500000 2793.5000 0.0000
S 2 5.000000 185.0000 0.0000
H 2558 10448.500000 531036.2700 170.0000
T 0 0.000000 0.0000 0.0000
4140 9702.000000 338689.2100 0.0000
Other 86 201.500000 13258.5200 396.8100
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Total 14145 40958.500000 1371341.8100 446263.9000