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
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 1188 1276.000000 47212.0000 37.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 554 2489.500000 92111.5000 37.0000
Subtotal (Total Children Is Unduplicated) 1386 3765.500000 139323.5000 37.0000
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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 6 5.500000 412.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 4 3.000000 225.0000 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 14 13.000000 721.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 41 31.500000 2362.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 55 44.500000 3337.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 235 190.000000 10545.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 66 47.000000 3525.0000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 26 26.000000 1531.6600 58.9100
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 2 2.000000 166.5800 83.2900
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 4 4.000000 93.6800 23.4200
MED-99214-OUTPATIENT VISIT, EST, 25 MINS 1 1.000000 36.4900 36.4900
OCTH-97166-OT EVAL MODERATE COMPLEXITY 1 1.000000 51.0500 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 8 8.000000 408.4000 51.0500
PSTH-97162-PT EVAL MODERATE COMPLEXITY 1 1.000000 51.0500 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 5 5.000000 255.2500 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 12 13.000000 663.6500 51.0500
SPCH-92524-BEHAV & QUAL ANALYSIS OF VOICE AND RES 2 2.000000 102.1000 51.0500
Subtotal (Total Children Is Unduplicated) 491 600.750000 34763.9100 57.8675
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 25 51.750000 2587.5000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 236 2122.000000 106100.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 1244 13417.00000 134170.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 11 49.250000 3518.4200 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 23 118.750000 6792.5000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 11 44.000000 3143.3600 71.4400
PHY-97110HM-PT SESSION BY PT ASST 12 55.000000 3143.8000 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 9 51.500000 3679.1600 71.4400
Subtotal (Total Children Is Unduplicated) 1283 15909.25000 263134.7400 16.5397
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Total 20275.500000 437222.1500 21.5641
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Number of Children (Unduplicated) With at Least One Service 1895
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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 4089 15898.750000 263782.1400 263698.6400
D 17 20.000000 843.7500 0.0000
S 0 0.000000 0.0000 0.0000
H 6 26.000000 260.0000 260.0000
T 0 0.000000 0.0000 0.0000
4806 4327.750000 172306.2600 0.0000
Other 1 3.000000 30.0000 30.0000
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Total 8919 20275.500000 437222.1500 263988.6400