CMS/EIP Fiscal Report Center: 04
Services beginning 10/01/2016 ending 12/31/2016 Date of Report:02/04/2017 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 17 15.500000 1478.2500 95.3710
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 54 51.500000 4682.7600 90.9274
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 14 14.000000 4256.0000 304.0000
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 2 2.000000 386.0000 193.0000
OCTH-97003-OT EVAL BY LICENSED OT, INITIAL 2 2.000000 102.1000 51.0500
PSTH-97001-EVAL BY LICENSED PT, INITIAL 2 2.000000 102.1000 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 1 1.000000 51.0500 51.0500
Subtotal (Total Children Is Unduplicated) 72 88.000000 11058.2600 125.6620
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EI Services,Class #03
OCCT-97530-OT SESSION BY LICENSED OT 4 17.000000 1214.4800 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 1 5.000000 286.0000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 3 5.000000 357.2000 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 8 33.500000 2393.2400 71.4400
Subtotal (Total Children Is Unduplicated) 14 60.500000 4250.9200 70.2631
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Total 148.500000 15309.1800 103.0921
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Number of Children (Unduplicated) With at Least One Service 82
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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 8 8.500000 1773.5100 1773.5100
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 1 2.000000 114.4000 0.0000
T 0 0.000000 0.0000 0.0000
80 75.500000 9080.5500 0.0000
Other 29 62.500000 4340.7200 678.6800
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Total 118 148.500000 15309.1800 2452.1900