CMS/EIP Fiscal Report Center: 04
Services beginning 07/01/2019 ending 09/30/2019 Date of Report:11/04/2019 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 1426 6628.000000 245181.5000 36.9918
Subtotal (Total Children Is Unduplicated) 1426 6628.000000 245181.5000 36.9918
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 12 9.000000 675.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 9 7.000000 525.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 0.500000 37.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 24 22.500000 1687.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 25 24.500000 1359.7500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 134 97.500000 7312.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 144 106.000000 7950.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 304 282.500000 15678.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 154 132.500000 9937.5000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 6 6.000000 353.4600 58.9100
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 1 1.000000 83.2900 83.2900
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 2 2.000000 46.8400 23.4200
OCTF-97168-OT RE-EVAL EST PLAN CARE 1 1.000000 51.0500 51.0500
OCTH-97166-OT EVAL MODERATE COMPLEXITY 6 6.000000 306.3000 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 21 21.000000 1072.0500 51.0500
PSTF-97164-PT RE-EVAL EST PLAN CARE 2 2.000000 102.1000 51.0500
PSTH-97162-PT EVAL MODERATE COMPLEXITY 13 13.000000 663.6500 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 5 5.000000 255.2500 51.0500
SPCH-92524-BEHAV & QUAL ANALYSIS OF VOICE AND RES 5 5.000000 255.2500 51.0500
SPCH-92610-EVAL OF ORAL,PHARYNGEAL SWALLOWING FUNC 12 12.000000 587.2800 48.9400
Subtotal (Total Children Is Unduplicated) 453 804.000000 51390.4200 63.9184
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1028 10739.00000 536950.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 40 157.500000 11251.8000 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 70 326.500000 18675.8000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 43 260.250000 18592.2600 71.4400
PHY-97110HM-PT SESSION BY PT ASST 87 447.750000 25593.3900 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 28 52.500000 3750.6000 71.4400
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 1 4.000000 228.8000 57.2000
SPL-92508-GROUP SPL SESSION PER CHILD 18 20.250000 281.0700 13.8800
Subtotal (Total Children Is Unduplicated) 1110 12007.75000 615323.7200 51.2439
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Total 19439.750000 911895.6400 46.9088
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Number of Children (Unduplicated) With at Least One Service 1597
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Center 04
Flag Claims Units Chgs Paid
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R 527 856.750000 31663.7500 37.0000
U 0 0.000000 0.0000 0.0000
B 828 1123.750000 44970.7500 0.0000
P 3633 5220.000000 206519.0900 201679.9200
D 1 1.500000 55.5000 0.0000
S 0 0.000000 0.0000 0.0000
H 3005 11870.500000 606255.7700 0.0000
T 0 0.000000 0.0000 0.0000
355 367.250000 22430.7800 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 8349 19439.750000 911895.6400 201716.9200