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: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 5 4.500000 337.5000 75.0000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 66 65.500000 4912.5000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 6 6.000000 1824.0000 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) 76 86.000000 7726.4500 89.8424
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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
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Total 187.000000 14742.5300 78.8371
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Number of Children (Unduplicated) With at Least One Service 90
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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 7 7.000000 521.4400 1390.1100
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
73 72.000000 6868.0500 0.0000
Other 46 108.000000 7353.0400 645.1400
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Total 126 187.000000 14742.5300 2035.2500