CMS/EIP Fiscal Report Center: 04
Services beginning 01/01/2016 ending 03/31/2016 Date of Report:05/12/2016 Page: 1
List order: No List
Payclass Filters:TPIN
Eligibility Filter:Part C (excluding not eligible)
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 5 4.500000 337.5000 75.0000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 52 51.500000 3862.5000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 5 5.000000 1520.0000 304.0000
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 1 1.000000 193.0000 193.0000
OCTF-97004-OT EVAL BY LICENSED OT, FOLLOW-UP 1 1.000000 51.0500 51.0500
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 6 6.000000 306.3000 51.0500
PSTF-97002-EVAL BY LICENSED PT, FOLLOW-UP 1 1.000000 51.0500 51.0500
SPCH-92524-BEHAV & QUAL ANALYSIS OF
VOICE AND RES 1 1.000000 51.0500 51.0500
Subtotal (Total Children Is Unduplicated) 62 71.000000 6372.4500 89.7528
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
OCCT-97530-OT SESSION BY LICENSED OT 10 38.500000 2750.4400 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 3 12.500000 715.0000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 6 34.500000 2464.6800 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 5 14.000000 1000.1600 71.4400
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 1 1.500000 85.8000 57.2000
Subtotal (Total Children Is Unduplicated) 21 101.000000 7016.0800 69.4661
-----------------------------------------------------------------------------------------------------------------------
Total 172.000000 13388.5300 77.8403
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 76
-----------------------------------------------------------------------------------------------------------------------
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 4 4.000000 296.4400 751.8700
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
61 60.000000 5739.0500 0.0000
Other 46 108.000000 7353.0400 645.1400
---------------------------------------------------------
Total 111 172.000000 13388.5300 1397.0100