CMS/EIP Fiscal Report Center: 04
Services beginning 01/01/2017 ending 03/31/2017 Date of Report:05/05/2017 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 13 16.500000 1237.5000 75.0000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 69 71.000000 6226.8700 87.7024
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 12 12.000000 3552.8300 296.0692
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 3 3.000000 579.0000 193.0000
OCTH-97167-OT EVAL HIGH COMPLEXITY 7 7.000000 357.3500 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 5 5.000000 255.2500 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 2 2.000000 102.1000 51.0500
Subtotal (Total Children Is Unduplicated) 89 116.500000 12310.9000 105.6730
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EI Services,Class #03
OCCT-97530-OT SESSION BY LICENSED OT 10 38.000000 2714.7200 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 3 14.000000 800.8000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 5 18.500000 1321.6400 71.4400
PHY-97110HM-PT SESSION BY PT ASST 7 45.000000 2572.2000 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 5 25.500000 1821.7200 71.4400
Subtotal (Total Children Is Unduplicated) 24 141.000000 9231.0800 65.4687
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Total 257.500000 21541.9800 83.6582
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Number of Children (Unduplicated) With at Least One Service 103
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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 18 41.500000 3738.4800 3738.4800
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 6 18.000000 1065.7300 0.0000
T 0 0.000000 0.0000 0.0000
91 96.500000 10110.5000 0.0000
Other 43 101.500000 6627.2700 1746.5500
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Total 158 257.500000 21541.9800 5485.0300