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:TPIN
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 1 1.750000 64.7500 37.0000
Subtotal (Total Children Is Unduplicated) 1 1.750000 64.7500 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 1.000000 75.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 4 4.000000 506.4400 126.6100
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 1.000000 55.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 18 13.500000 1012.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 14 13.500000 1012.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 39 49.500000 2721.7500 54.9848
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 69 82.500000 8357.5400 101.3035
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 16 16.000000 4142.2600 258.8913
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 3 3.000000 1253.9300 417.9767
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 2 2.000000 111.9700 55.9850
OCTH-97166-OT EVAL MODERATE COMPLEXITY 1 1.000000 51.0500 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 9 9.000000 409.4500 45.4944
PSTH-97163-PT EVAL HIGH COMPLEXITY 13 13.000000 643.6500 49.5115
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 1 1.000000 51.0500 51.0500
SPCH-92524-BEHAV & QUAL ANALYSIS OF VOICE AND RES 9 9.000000 414.4500 46.0500
Subtotal (Total Children Is Unduplicated) 105 219.000000 20819.0400 95.0641
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EI Services,Class #03
OCCT-97530-OT SESSION BY LICENSED OT 29 123.000000 8175.2400 66.4654
OCCT-97530HM-OT SESSION BY OT ASST 8 36.500000 2087.8000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 13 68.500000 4217.5000 61.5693
PHY-97110HM-PT SESSION BY PT ASST 6 36.500000 2086.3400 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 32 141.000000 9704.1500 68.8238
Subtotal (Total Children Is Unduplicated) 64 405.500000 26271.0300 64.7868
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Total 626.250000 47154.8200 75.2971
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Number of Children (Unduplicated) With at Least One Service 140
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Center 04
Flag Claims Units Chgs Paid
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R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 0 0.000000 0.0000 0.0000
P 138 260.000000 18875.6800 15512.7900
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
175 163.750000 14564.8300 0.0000
Other 75 202.500000 13714.3100 0.0000
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Total 388 626.250000 47154.8200 15512.7900