CMS/EIP Fiscal Report Center: 04
Services beginning 10/01/2015 ending 12/31/2015 Date of Report:02/13/2016 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 9 8.000000 1252.5000 156.5625
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 68 60.500000 9105.0000 150.4959
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 17 17.000000 4952.0000 291.2941
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 1 1.000000 507.0000 507.0000
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 1 1.000000 280.0000 280.0000
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 1 1.000000 51.0500 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 1 1.000000 51.0500 51.0500
Subtotal (Total Children Is Unduplicated) 79 89.500000 16198.6000 180.9899
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
OCCT-97530-OT SESSION BY LICENSED OT 3 9.500000 678.6800 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 1 7.000000 400.4000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 7 40.000000 2857.6000 71.4400
PHY-97110HM-PT SESSION BY PT ASST 3 21.000000 1200.3600 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 6 21.000000 1500.2400 71.4400
Subtotal (Total Children Is Unduplicated) 18 98.500000 6637.2800 67.3836
-----------------------------------------------------------------------------------------------------------------------
Total 188.000000 22835.8800 121.4674
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 91
-----------------------------------------------------------------------------------------------------------------------
Center 04
Flag Claims Units Chgs Paid
---------------------------------------------------------
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 36 32.000000 9270.5000 7110.7500
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 1 3.000000 171.4800 0.0000
T 0 0.000000 0.0000 0.0000
60 55.500000 6826.0000 43.1800
Other 36 97.500000 6567.9000 551.1300
---------------------------------------------------------
Total 133 188.000000 22835.8800 7705.0600