CMS/EIP Fiscal Report Center: 04
Services beginning 01/01/2018 ending 03/31/2018 Date of Report:05/05/2018 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 855 867.250000 32088.2500 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 1708 7455.500000 275853.5000 37.0000
Subtotal (Total Children Is Unduplicated) 1737 8322.750000 307941.7500 37.0000
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Screening, Eval, and Assessment,Class #02
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 35 35.000000 885.8500 25.3100
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 35 35.000000 649.2500 18.5500
EVAL-96111-DEVELOPMENTAL EVALUATION 76 86.500000 4325.0000 50.0000
EXIT-EXIT-EXIT ASSESSMENT 116 137.250000 6862.5000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 27 22.000000 1650.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 30 24.000000 1800.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 38 36.500000 3331.7100 91.2797
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 51 60.000000 3330.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 152 117.500000 8812.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 203 170.500000 12787.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 407 499.000000 27694.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 236 231.000000 20166.2200 87.2997
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 145 146.000000 13212.2500 90.4949
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 1 1.000000 507.0000 507.0000
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 21 21.000000 1114.0300 53.0490
OCTF-97168-OT RE-EVAL EST PLAN CARE 5 5.000000 255.2500 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 62 63.000000 3176.1500 50.4151
PSTF-97164-PT RE-EVAL EST PLAN CARE 1 1.000000 51.0500 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 59 59.000000 2996.9500 50.7958
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 42 42.000000 2144.1000 51.0500
SPCH-92524-BEHAV & QUAL ANALYSIS OF
VOICE AND RES 3 3.000000 153.1500 51.0500
Subtotal (Total Children Is Unduplicated) 754 1795.250000 115904.9600 64.5620
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 34 69.750000 3487.5000 50.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 8 8.000000 400.0000 50.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 2 2.000000 100.0000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 3 3.000000 150.0000 50.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 64 5379.000000 134475.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1102 10517.00000 525850.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 1122 11022.00000 110220.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 105 599.000000 42638.8400 71.1834
OCCT-97530HM-OT SESSION BY OT ASST 34 173.500000 9924.2000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 77 369.000000 26102.9700 70.7398
PHY-97110HM-PT SESSION BY PT ASST 87 625.500000 35753.5800 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 74 351.750000 25093.3000 71.3385
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 4 8.000000 457.6000 57.2000
Subtotal (Total Children Is Unduplicated) 1310 29127.50000 914652.9900 31.4017
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Total 39245.500000 1338499.7000 34.1058
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Number of Children (Unduplicated) With at Least One Service 1940
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Center 04
Flag Claims Units Chgs Paid
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R 17 15.000000 555.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 303 459.750000 17158.8000 0.0000
P 6753 18733.000000 453164.7100 453300.2350
D 8 5.750000 212.7500 0.0000
S 1 1.500000 55.5000 0.0000
H 2306 9523.500000 487610.6400 350.0000
T 0 0.000000 0.0000 0.0000
4782 10268.000000 364087.4300 0.0000
Other 96 239.000000 15654.8700 322.9000
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Total 14266 39245.500000 1338499.7000 453973.1350