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:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 1259 5245.000000 194065.0000 37.0000
Subtotal (Total Children Is Unduplicated) 1259 5245.000000 194065.0000 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 20 16.500000 1237.5000 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 31 38.000000 2109.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 105 82.000000 6150.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 139 115.000000 8625.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 289 271.500000 15068.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 89 66.000000 4950.0000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 53 54.000000 2891.7000 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) 409 771.000000 47993.0300 62.2478
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 882 8440.000000 422000.0000 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) 971 9735.250000 507046.2800 52.0835
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Total 15751.250000 749104.3100 47.5584
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Number of Children (Unduplicated) With at Least One Service 1477
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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 303 459.750000 17158.8000 0.0000
P 3307 5185.250000 203697.5600 203833.0850
D 0 0.000000 0.0000 0.0000
S 1 1.500000 55.5000 0.0000
H 2285 9435.000000 483944.8300 0.0000
T 0 0.000000 0.0000 0.0000
423 653.250000 43637.1200 0.0000
Other 1 1.500000 55.5000 0.0000
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Total 6337 15751.250000 749104.3100 203833.0850