CMS/EIP Fiscal Report Center: 04
Services beginning 01/01/2017 ending 03/31/2017 Date of Report:05/05/2017 Page: 1
List order: No List
Payclass Filters:MED
Eligibility Filter:Part C (excluding not eligible)
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 1314 5637.000000 208569.0000 37.0000
Subtotal (Total Children Is Unduplicated) 1314 5637.000000 208569.0000 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 19 13.500000 1012.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 17 13.000000 975.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 15 9.000000 675.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 28 33.500000 2512.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 27 28.000000 1554.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 140 108.000000 8100.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 122 95.000000 7125.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 74 48.000000 3600.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 243 245.000000 13597.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 162 153.500000 11512.5000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 36 36.000000 1875.6000 52.1000
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 1 1.000000 75.7200 75.7200
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 7 7.000000 181.8000 25.9714
OCTF-97168-OT RE-EVAL EST PLAN CARE 2 2.000000 102.1000 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 13 13.000000 663.6500 51.0500
PSTF-97164-PT RE-EVAL EST PLAN CARE 5 5.000000 255.2500 51.0500
PSTH-97161-PT EVAL LOW COMPLEXITY 2 2.000000 102.1000 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 20 20.000000 1021.0000 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) 433 846.500000 55655.9200 65.7483
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 904 8457.000000 422703.0000 49.9826
OCCT-97530-OT SESSION BY LICENSED OT 36 246.000000 17502.8000 71.1496
OCCT-97530HM-OT SESSION BY OT ASST 7 19.000000 1086.8000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 22 155.500000 11108.9200 71.4400
PHY-97110HM-PT SESSION BY PT ASST 21 185.000000 10574.6000 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 21 109.000000 7786.9600 71.4400
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 1 1.000000 57.2000 57.2000
Subtotal (Total Children Is Unduplicated) 958 9172.500000 470820.2800 51.3295
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Total 15656.000000 735045.2000 46.9497
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Number of Children (Unduplicated) With at Least One Service 1446
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Center 04
Flag Claims Units Chgs Paid
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R 1 1.000000 55.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 741 930.750000 41169.0000 0.0000
P 3269 4847.750000 190520.3900 190484.9000
D 0 0.000000 0.0000 0.0000
S 2 2.000000 74.0000 0.0000
H 2251 8850.000000 447238.7500 228.6400
T 0 0.000000 0.0000 0.0000
653 1018.000000 55523.2000 0.0000
Other 2 6.500000 464.3600 178.6000
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Total 6919 15656.000000 735045.2000 190892.1400