CMS/EIP Fiscal Report Center: 04
Services beginning 10/01/2017 ending 12/31/2017 Date of Report:02/03/2018 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 7 8.000000 600.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 2 2.500000 187.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 1 0.500000 27.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 61 65.000000 5846.6800 89.9489
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 23 23.000000 6353.6600 276.2461
OCTH-97167-OT EVAL HIGH COMPLEXITY 5 5.000000 255.2500 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 7 7.000000 357.3500 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 5 5.000000 255.2500 51.0500
SPCH-92524-BEHAV & QUAL ANALYSIS OF
VOICE AND RES 1 1.000000 51.0500 51.0500
Subtotal (Total Children Is Unduplicated) 81 117.000000 13934.4900 119.0982
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EI Services,Class #03
OCCT-97530-OT SESSION BY LICENSED OT 16 78.000000 5536.6000 70.9821
OCCT-97530HM-OT SESSION BY OT ASST 4 30.500000 1744.6000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 7 34.000000 2357.5200 69.3388
PHY-97110HM-PT SESSION BY PT ASST 8 52.000000 2972.3200 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 17 79.000000 5643.7600 71.4400
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 1 12.500000 715.0000 57.2000
Subtotal (Total Children Is Unduplicated) 45 286.000000 18969.8000 66.3280
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Total 403.000000 32904.2900 81.6484
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Number of Children (Unduplicated) With at Least One Service 110
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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 50 112.500000 8300.8100 8300.8100
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 1 5.000000 357.2000 0.0000
T 0 0.000000 0.0000 0.0000
83 88.000000 11170.2500 0.0000
Other 81 197.500000 13076.0300 336.8100
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Total 215 403.000000 32904.2900 8637.6200