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:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 1328 5310.750000 196497.7500 37.0000
Subtotal (Total Children Is Unduplicated) 1328 5310.750000 196497.7500 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 19 13.000000 975.0000 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 40 38.000000 2109.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 94 73.500000 5512.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 154 137.500000 10312.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 273 259.000000 14374.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 93 74.000000 5550.0000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 46 46.000000 2463.3000 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) 391 762.000000 48083.0400 63.1011
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 950 9692.000000 484600.0000 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) 1020 10797.00000 558210.4400 51.7005
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Total 16869.750000 802791.2300 47.5876
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Number of Children (Unduplicated) With at Least One Service 1518
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Center 04
Flag Claims Units Chgs Paid
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R 44 61.250000 2266.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 621 960.750000 37359.2500 0.0000
P 2941 4661.750000 182921.9900 183076.8700
D 0 0.000000 0.0000 0.0000
S 2 5.000000 185.0000 0.0000
H 2549 10417.500000 530059.0700 0.0000
T 0 0.000000 0.0000 0.0000
516 763.500000 49999.6700 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 6673 16869.750000 802791.2300 183076.8700