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
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 855 867.250000 32088.2500 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 514 2210.500000 81788.5000 37.0000
Subtotal (Total Children Is Unduplicated) 1092 3077.750000 113876.7500 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 11 10.500000 787.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 10 7.500000 562.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 12 8.500000 637.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 28 22.000000 1221.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 46 35.000000 2625.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 64 55.500000 4162.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 264 226.000000 12543.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 85 59.500000 4462.5000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 66 66.000000 3534.3000 53.5500
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 9 9.000000 239.4900 26.6100
OCTF-97168-OT RE-EVAL EST PLAN CARE 1 1.000000 51.0500 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 25 25.000000 1276.2500 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 9 9.000000 459.4500 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 20 20.000000 1021.0000 51.0500
SPCH-92524-BEHAV & QUAL ANALYSIS OF
VOICE AND RES 2 2.000000 102.1000 51.0500
Subtotal (Total Children Is Unduplicated) 597 850.250000 46407.7400 54.5813
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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
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 227 1990.000000 99500.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 1122 11022.00000 110220.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 32 158.000000 11287.5200 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 15 62.500000 3575.0000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 9 49.500000 3393.4000 68.5535
PHY-97110HM-PT SESSION BY PT ASST 11 68.000000 3886.8800 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 15 70.000000 5000.8000 71.4400
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 1 3.000000 171.6000 57.2000
Subtotal (Total Children Is Unduplicated) 1172 13505.75000 241172.7000 17.8570
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Total 17433.750000 401457.1900 23.0276
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Number of Children (Unduplicated) With at Least One Service 1734
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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 3383 13449.750000 239165.8600 239165.8600
D 8 5.750000 212.7500 0.0000
S 0 0.000000 0.0000 0.0000
H 19 81.000000 3130.0100 350.0000
T 0 0.000000 0.0000 0.0000
3894 3873.750000 157602.8400 0.0000
Other 9 23.500000 1345.7300 180.0000
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Total 7313 17433.750000 401457.1900 239695.8600