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
Payclass Filters:GR
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 497 2204.000000 81548.0000 37.0000
Subtotal (Total Children Is Unduplicated) 1146 3204.500000 118566.5000 37.0000
-----------------------------------------------------------------------------------------------------------------------
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-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 1.000000 75.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 6 4.500000 337.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 12 6.500000 360.7500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 11 8.000000 600.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 26 24.500000 1837.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 121 96.000000 5328.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 41 31.500000 2362.5000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 44 44.000000 2592.0400 58.9100
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 2 2.000000 166.5800 83.2900
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 5 5.000000 117.1000 23.4200
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-97167-OT EVAL HIGH COMPLEXITY 18 18.000000 918.9000 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 2 2.000000 102.1000 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 13 13.000000 663.6500 51.0500
SPCH-92524-BEHAV & QUAL ANALYSIS OF VOICE AND RES 1 1.000000 51.0500 51.0500
Subtotal (Total Children Is Unduplicated) 398 462.000000 25764.7700 55.7679
-----------------------------------------------------------------------------------------------------------------------
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
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 222 2076.000000 103800.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 1203 12538.00000 125380.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 27 155.000000 11073.2000 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 18 98.000000 5605.6000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 9 47.000000 3179.0800 67.6400
PHY-97110HM-PT SESSION BY PT ASST 9 41.000000 2343.5600 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 13 90.500000 6465.3200 71.4400
Subtotal (Total Children Is Unduplicated) 1260 15157.75000 263459.2600 17.3812
-----------------------------------------------------------------------------------------------------------------------
Total 18824.250000 407790.5300 21.6630
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 1720
-----------------------------------------------------------------------------------------------------------------------
Center 04
Flag Claims Units Chgs Paid
---------------------------------------------------------
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 3792 15055.750000 259544.6600 259544.6600
D 28 37.500000 1387.5000 0.0000
S 0 0.000000 0.0000 0.0000
H 30 117.500000 4843.6900 834.6400
T 0 0.000000 0.0000 0.0000
3895 3604.000000 141667.5200 0.0000
Other 3 9.500000 347.1600 347.1600
---------------------------------------------------------
Total 7748 18824.250000 407790.5300 260726.4600