CMS/EIP Fiscal Report Center: 04
Services beginning 10/01/2018 ending 12/31/2018 Date of Report:02/06/2019 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 1278 5347.250000 197848.2500 37.0000
Subtotal (Total Children Is Unduplicated) 1278 5347.250000 197848.2500 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 16 14.000000 1050.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 15 12.000000 900.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 17 14.500000 1087.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 28 30.000000 1665.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 92 77.500000 5812.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 124 99.500000 7462.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 254 252.500000 14013.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 94 78.500000 5887.5000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 19 19.000000 1119.2900 58.9100
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 6 6.000000 499.7400 83.2900
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 9 9.000000 210.7800 23.4200
MED-99214-OUTPATIENT VISIT, EST, 25 MINS 1 1.000000 36.4900 36.4900
OCTH-97167-OT EVAL HIGH COMPLEXITY 20 20.000000 1021.0000 51.0500
PSTF-97164-PT RE-EVAL EST PLAN CARE 2 2.000000 102.1000 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 32 32.000000 1633.6000 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 3 3.000000 153.1500 51.0500
SPCH-92524-BEHAV & QUAL ANALYSIS OF VOICE AND RES 4 4.000000 204.2000 51.0500
Subtotal (Total Children Is Unduplicated) 342 674.500000 42859.1000 63.5420
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EI Services,Class #03
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 1 4.000000 100.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 965 9946.000000 497300.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 49 256.500000 18324.3600 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 31 199.500000 11411.4000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 31 231.000000 16502.6400 71.4400
PHY-97110HM-PT SESSION BY PT ASST 55 334.000000 19091.4400 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 24 137.750000 9840.8600 71.4400
Subtotal (Total Children Is Unduplicated) 1030 11108.75000 572570.7000 51.5423
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Total 17130.500000 813278.0500 47.4754
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Number of Children (Unduplicated) With at Least One Service 1454
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Center 04
Flag Claims Units Chgs Paid
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R 8 8.500000 314.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 1146 1666.000000 64344.7500 0.0000
P 2608 4065.750000 160912.3800 158214.8900
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 2542 10804.500000 549833.7000 0.0000
T 0 0.000000 0.0000 0.0000
395 585.750000 37872.7200 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 6699 17130.500000 813278.0500 158214.8900