CMS/EIP Fiscal Report Center: 04
Services beginning 10/01/2017 ending 12/31/2017 Date of Report:02/03/2018 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 1243 4790.250000 177239.2500 37.0000
Subtotal (Total Children Is Unduplicated) 1243 4790.250000 177239.2500 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 16 11.000000 825.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 28 24.500000 1837.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 10 9.500000 712.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 37 36.000000 1998.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 66 52.500000 3937.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 119 110.500000 8287.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 204 194.500000 10794.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 68 59.000000 4425.0000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 36 36.000000 1927.8000 53.5500
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 8 8.000000 212.8800 26.6100
MED-99214-OUTPATIENT VISIT, EST, 25 MINS 1 1.000000 41.4600 41.4600
OCTF-97168-OT RE-EVAL EST PLAN CARE 2 2.000000 102.1000 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 15 15.000000 765.7500 51.0500
PSTF-97164-PT RE-EVAL EST PLAN CARE 7 7.000000 357.3500 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 37 37.000000 1888.8500 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 17 17.000000 867.8500 51.0500
Subtotal (Total Children Is Unduplicated) 314 620.500000 38981.7900 62.8232
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 949 9679.000000 483950.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 46 346.750000 24771.8200 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 10 66.500000 3803.8000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 39 222.750000 15913.2600 71.4400
PHY-97110HM-PT SESSION BY PT ASST 38 303.000000 17319.4800 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 21 162.000000 11573.2800 71.4400
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 1 4.000000 228.8000 57.2000
Subtotal (Total Children Is Unduplicated) 1019 10784.00000 557560.4400 51.7026
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Total 16194.750000 773781.4800 47.7798
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Number of Children (Unduplicated) With at Least One Service 1431
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Center 04
Flag Claims Units Chgs Paid
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R 40 45.750000 1692.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 579 888.000000 34253.0000 0.0000
P 2661 4139.000000 161421.5900 161534.5900
D 0 0.000000 0.0000 0.0000
S 1 3.000000 111.0000 0.0000
H 2546 10404.500000 529409.0700 0.0000
T 0 0.000000 0.0000 0.0000
455 714.500000 46894.0700 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 6282 16194.750000 773781.4800 161534.5900