CMS/EIP Fiscal Report Center: 04
Services beginning 10/01/2013 ending 12/31/2013 Date of Report:02/18/2014 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
Screening, Eval, and Assessment,Class #02
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 8 5.000000 375.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 4 3.000000 166.5000 55.5000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 30 28.000000 1554.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 52 44.500000 3337.5000 75.0000
MED-99202-OUTPATIENT VISIT, NEW, 20 MINS 3 3.000000 570.0000 190.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 39 39.000000 10920.0000 280.0000
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 1 1.000000 420.0000 420.0000
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 8 8.000000 1440.0000 180.0000
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 1 1.000000 48.5000 48.5000
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 3 3.000000 145.5000 48.5000
PSTH-97001-EVAL BY LICENSED PT, INITIAL 3 3.000000 145.5000 48.5000
SPCH-92506-SPEECH EVAL BY LICENSED SLP 1 1.000000 48.5000 48.5000
Subtotal (Total Children Is Unduplicated) 102 139.500000 19171.0000 137.4265
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 5 24.000000 1200.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 10 39.000000 2647.3200 67.8800
OCCT-97530HM-OT SESSION BY OT ASST 2 13.000000 706.1600 54.3200
PHY-97110-PT SESSION BY LICENSED PT 22 88.000000 5973.4400 67.8800
PHY-97110HM-PT SESSION BY PT ASST 4 8.500000 461.7200 54.3200
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 9 49.000000 3326.1200 67.8800
TRAV-FLAT-PROV TRAVEL TO NATL ENV $10 PER CHILD 1 1.000000 10.0000 10.0000
Subtotal (Total Children Is Unduplicated) 47 222.500000 14324.7600 64.3809
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Total 362.000000 33495.7600 92.5297
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Number of Children (Unduplicated) With at Least One Service 135
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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 44 62.000000 5957.6600 7184.0800
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 2 7.000000 421.5200 150.0000
T 0 0.000000 0.0000 0.0000
110 97.500000 14350.5000 0.0000
Other 83 195.500000 12766.0800 7549.7300
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Total 239 362.000000 33495.7600 14883.8100