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:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 1346 5774.250000 213647.2500 37.0000
Subtotal (Total Children Is Unduplicated) 1346 5774.250000 213647.2500 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 18 16.000000 1200.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 16 12.500000 937.5000 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 31 33.000000 1831.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 113 95.000000 7125.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 150 121.000000 9075.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 314 304.000000 16872.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 114 91.500000 6862.5000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 21 21.000000 1237.1100 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) 406 785.500000 50089.1700 63.7672
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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 17668.500000 836307.1200 47.3332
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Number of Children (Unduplicated) With at Least One Service 1522
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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 1207 1769.000000 68749.0000 0.0000
P 2815 4449.500000 176268.8800 173571.3900
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
456 637.000000 41141.0400 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 7028 17668.500000 836307.1200 173571.3900