CMS/EIP Fiscal Report Center: 04
Services beginning 07/01/2019 ending 09/30/2019 Date of Report:11/04/2019 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 1188 1276.000000 47212.0000 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 1865 9117.500000 337293.0000 36.9940
Subtotal (Total Children Is Unduplicated) 1919 10393.50000 384505.0000 36.9948
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Screening, Eval, and Assessment,Class #02
EVAL-96111-DEVELOPMENTAL EVALUATION 86 87.500000 4375.0000 50.0000
EXIT-EXIT-EXIT ASSESSMENT 112 111.250000 5562.5000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 18 14.500000 1087.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 14 11.500000 862.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 0.500000 37.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 35 35.500000 2662.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 34 38.500000 2136.7500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 177 130.500000 9787.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 203 153.500000 11512.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 425 480.500000 26667.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 266 261.000000 19960.5500 76.4772
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 42 42.000000 4925.1200 117.2648
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 5 5.000000 1263.8700 252.7740
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 6 6.000000 140.5200 23.4200
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-97166-OT EVAL MODERATE COMPLEXITY 11 11.000000 561.5500 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 34 34.000000 1735.7000 51.0500
PSTF-97164-PT RE-EVAL EST PLAN CARE 2 2.000000 102.1000 51.0500
PSTH-97162-PT EVAL MODERATE COMPLEXITY 19 19.000000 969.9500 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 62 62.000000 3165.1000 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 21 22.000000 1123.1000 51.0500
SPCH-92524-BEHAV & QUAL ANALYSIS OF VOICE AND RES 13 13.000000 663.6500 51.0500
SPCH-92610-EVAL OF ORAL,PHARYNGEAL SWALLOWING FUNC 13 13.000000 636.2200 48.9400
Subtotal (Total Children Is Unduplicated) 793 1555.750000 100026.9700 64.2950
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 25 51.750000 2587.5000 50.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 77 2982.000000 74550.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1246 12902.00000 645100.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 1244 13417.00000 134170.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 67 289.250000 20664.0200 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 99 520.750000 29784.9800 57.1963
PHY-97110-PT SESSION BY LICENSED PT 69 400.750000 28408.1400 70.8874
PHY-97110HM-PT SESSION BY PT ASST 100 530.250000 30309.0900 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 55 201.000000 14109.4000 70.1960
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 1 4.000000 228.8000 57.2000
SPL-92508-GROUP SPL SESSION PER CHILD 23 26.500000 367.8200 13.8800
Subtotal (Total Children Is Unduplicated) 1419 31325.25000 980279.7500 31.2936
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Total 43274.500000 1464811.7200 33.8493
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Number of Children (Unduplicated) With at Least One Service 2076
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Center 04
Flag Claims Units Chgs Paid
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R 527 856.750000 31663.7500 37.0000
U 0 0.000000 0.0000 0.0000
B 828 1123.750000 44970.7500 0.0000
P 7831 21371.250000 486965.5400 477032.8800
D 18 21.500000 899.2500 0.0000
S 0 0.000000 0.0000 0.0000
H 3021 11940.500000 608737.3700 260.0000
T 0 0.000000 0.0000 0.0000
5453 7814.250000 282026.9700 0.0000
Other 68 146.500000 9548.0900 30.0000
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Total 17746 43274.500000 1464811.7200 477359.8800