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: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 1052 1055.250000 39044.2500 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 1779 8206.500000 303640.5000 37.0000
Subtotal (Total Children Is Unduplicated) 1817 9261.750000 342684.7500 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-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 19 17.000000 1275.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 18 14.000000 1050.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 23 23.000000 1931.4400 83.9757
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 35 42.000000 2331.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 149 123.000000 9225.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 195 162.500000 12187.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 408 472.000000 26170.5000 55.4460
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 210 212.500000 18107.5400 85.2120
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 90 90.000000 8501.6000 94.4622
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) 715 1518.000000 99898.7200 65.8094
-----------------------------------------------------------------------------------------------------------------------
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
-----------------------------------------------------------------------------------------------------------------------
Total 43392.500000 1462829.8800 33.7116
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 2006
-----------------------------------------------------------------------------------------------------------------------
Center 04
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 8 8.500000 314.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 1207 1769.000000 68749.0000 0.0000
P 6745 19765.250000 454689.2200 448628.8400
D 29 42.500000 1572.5000 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
5198 10673.250000 368765.8000 0.0000
Other 78 212.000000 14061.4700 347.1600
---------------------------------------------------------
Total 15837 43392.500000 1462829.8800 449810.6400