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: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 13 16.500000 1237.5000 75.0000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 96 98.000000 8416.5700 85.8834
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 15 15.000000 4464.8300 297.6553
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) 116 146.500000 15412.6000 105.2055
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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 6 20.000000 1428.8000 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) 25 142.500000 9338.2400 65.5315
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Total 289.000000 24750.8400 85.6430
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Number of Children (Unduplicated) With at Least One Service 131
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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 19 42.500000 3978.1800 3978.1800
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
120 125.500000 12972.5000 0.0000
Other 44 103.000000 6734.4300 1746.5500
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Total 189 289.000000 24750.8400 5724.7300