CMS/EIP Fiscal Report Center: 04
Services beginning 01/01/2018 ending 03/31/2018 Date of Report:05/05/2018 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 1186 4819.750000 178330.7500 37.0000
Subtotal (Total Children Is Unduplicated) 1186 4819.750000 178330.7500 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 16 11.500000 862.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 19 16.000000 1200.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 18 14.500000 1087.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 30 37.000000 2053.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 75 60.500000 4537.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 110 93.000000 6975.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 223 212.500000 11793.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 76 58.500000 4387.5000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 43 44.000000 2356.2000 53.5500
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 8 8.000000 212.8800 26.6100
OCTF-97168-OT RE-EVAL EST PLAN CARE 4 4.000000 204.2000 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 27 28.000000 1429.4000 51.0500
PSTF-97164-PT RE-EVAL EST PLAN CARE 1 1.000000 51.0500 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 48 48.000000 2450.4000 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 12 12.000000 612.6000 51.0500
SPCH-92524-BEHAV & QUAL ANALYSIS OF
VOICE AND RES 1 1.000000 51.0500 51.0500
Subtotal (Total Children Is Unduplicated) 340 649.500000 40265.0300 61.9939
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 880 8425.000000 421250.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 59 343.000000 24503.9200 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 17 86.500000 4947.8000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 43 267.500000 19110.2000 71.4400
PHY-97110HM-PT SESSION BY PT ASST 49 434.500000 24836.0200 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 26 162.750000 11591.1400 71.2205
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 1 1.000000 57.2000 57.2000
Subtotal (Total Children Is Unduplicated) 969 9720.250000 506296.2800 52.0868
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Total 15189.500000 724892.0600 47.7232
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Number of Children (Unduplicated) With at Least One Service 1393
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Center 04
Flag Claims Units Chgs Paid
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R 17 15.000000 555.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 295 434.500000 16224.5500 0.0000
P 3045 4712.250000 184141.2100 184230.4150
D 0 0.000000 0.0000 0.0000
S 1 1.500000 55.5000 0.0000
H 2281 9420.000000 483194.8300 0.0000
T 0 0.000000 0.0000 0.0000
369 604.750000 40665.4700 0.0000
Other 1 1.500000 55.5000 0.0000
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Total 6009 15189.500000 724892.0600 184230.4150