CMS/EIP Fiscal Report Center: 04
Services beginning 10/01/2018 ending 12/31/2018 Date of Report:02/06/2019 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 975 1000.500000 37018.5000 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 1675 7553.000000 279461.0000 37.0000
Subtotal (Total Children Is Unduplicated) 1712 8553.500000 316479.5000 37.0000
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Screening, Eval, and Assessment,Class #02
EVAL-96111-DEVELOPMENTAL EVALUATION 74 81.250000 4062.5000 50.0000
EXIT-EXIT-EXIT ASSESSMENT 111 121.750000 6087.5000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 16 14.000000 1050.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 16 13.000000 975.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 21 20.500000 1743.9400 85.0702
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 30 36.500000 2025.7500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 113 93.500000 7012.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 157 130.500000 9787.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 318 378.000000 20979.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 161 168.500000 14065.3600 83.4739
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 76 76.000000 7348.6900 96.6933
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 11 11.000000 1920.2500 174.5682
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 16 16.000000 439.8500 27.4906
MED-99214-OUTPATIENT VISIT, EST, 25 MINS 1 1.000000 36.4900 36.4900
OCTF-97168-OT RE-EVAL EST PLAN CARE 1 1.000000 51.0500 51.0500
OCTH-97165-OT EVAL LOW COMPLEXITY 1 1.000000 51.0500 51.0500
OCTH-97166-OT EVAL MODERATE COMPLEXITY 1 1.000000 51.0500 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 46 47.000000 2349.3500 49.9862
PSTF-97164-PT RE-EVAL EST PLAN CARE 2 2.000000 102.1000 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 48 48.000000 2430.4000 50.6333
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 17 17.000000 867.8500 51.0500
SPCH-92524-BEHAV & QUAL ANALYSIS OF VOICE AND RES 14 14.000000 669.7000 47.8357
Subtotal (Total Children Is Unduplicated) 618 1292.500000 84106.8800 65.0730
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 45 110.250000 5512.5000 50.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 2 2.000000 100.0000 50.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 70 5677.000000 141925.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1183 12107.00000 605350.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 1203 12538.00000 125380.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 101 534.500000 37572.8000 70.2952
OCCT-97530HM-OT SESSION BY OT ASST 55 334.000000 19104.8000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 69 373.500000 25828.1000 69.1515
PHY-97110HM-PT SESSION BY PT ASST 101 494.500000 28265.6200 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 94 442.000000 31207.5900 70.6054
Subtotal (Total Children Is Unduplicated) 1394 32612.75000 1020246.4100 31.2837
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Total 42458.750000 1420832.7900 33.4638
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Number of Children (Unduplicated) With at Least One Service 1901
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Center 04
Flag Claims Units Chgs Paid
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R 8 8.500000 314.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 1146 1666.000000 64344.7500 0.0000
P 6531 19374.500000 438043.5500 431983.1700
D 28 37.500000 1387.5000 0.0000
S 0 0.000000 0.0000 0.0000
H 2572 10922.000000 554677.3900 834.6400
T 0 0.000000 0.0000 0.0000
4779 10238.250000 348003.6300 0.0000
Other 78 212.000000 14061.4700 347.1600
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Total 15142 42458.750000 1420832.7900 433164.9700