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:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 1378 5978.000000 221186.0000 37.0000
Subtotal (Total Children Is Unduplicated) 1378 5978.000000 221186.0000 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 159 121.000000 9075.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 138 106.500000 7987.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 93 59.000000 4425.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 280 276.500000 15345.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 185 170.000000 12750.0000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 37 37.000000 1929.1500 52.1392
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) 488 931.000000 61357.7200 65.9052
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 905 8470.000000 423353.0000 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) 959 9185.500000 471470.2800 51.3277
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Total 16094.500000 754014.0000 46.8492
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Number of Children (Unduplicated) With at Least One Service 1510
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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 795 998.750000 44354.7500 0.0000
P 3449 5166.500000 203352.1400 203316.6500
D 0 0.000000 0.0000 0.0000
S 2 2.000000 74.0000 0.0000
H 2254 8863.000000 447888.7500 228.6400
T 0 0.000000 0.0000 0.0000
699 1056.750000 57824.5000 0.0000
Other 2 6.500000 464.3600 178.6000
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Total 7202 16094.500000 754014.0000 203723.8900