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
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 911 815.500000 30173.5000 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 477 1646.750000 60929.7500 37.0000
Subtotal (Total Children Is Unduplicated) 1122 2462.250000 91103.2500 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 4 3.000000 225.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 2 1.500000 112.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 11 6.000000 450.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 18 10.500000 582.7500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 33 26.500000 1987.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 44 37.000000 2775.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 201 160.500000 8907.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 74 55.000000 4125.0000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 60 60.000000 3213.0000 53.5500
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 2 2.000000 151.4400 75.7200
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 5 5.000000 133.0500 26.6100
OCTH-97167-OT EVAL HIGH COMPLEXITY 15 15.000000 765.7500 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 4 5.000000 255.2500 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 12 12.000000 612.6000 51.0500
Subtotal (Total Children Is Unduplicated) 491 598.000000 34246.5900 57.2685
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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
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 196 2073.000000 103650.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 1144 12219.00000 122190.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 29 176.500000 12609.1600 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 15 97.000000 5548.4000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 3 19.000000 1357.3600 71.4400
PHY-97110HM-PT SESSION BY PT ASST 8 38.000000 2172.0800 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 9 40.000000 2857.6000 71.4400
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 1 8.500000 486.2000 57.2000
Subtotal (Total Children Is Unduplicated) 1185 14735.75000 254108.3000 17.2443
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Total 17796.000000 379458.1400 21.3227
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Number of Children (Unduplicated) With at Least One Service 1757
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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 3655 14729.750000 254531.0100 254319.4100
D 48 75.500000 2793.5000 0.0000
S 0 0.000000 0.0000 0.0000
H 8 26.000000 620.0000 170.0000
T 0 0.000000 0.0000 0.0000
3171 2960.750000 121331.1400 0.0000
Other 5 4.000000 182.4900 60.0000
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Total 6887 17796.000000 379458.1400 254549.4100