CMS/EIP Fiscal Report Center: 04
Services beginning 01/01/2018 ending 03/31/2018 Date of Report:05/05/2018 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 14 13.500000 1606.7100 119.0156
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 1 0.500000 37.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 2 1.500000 83.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 96 105.500000 10753.7200 101.9310
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 26 26.000000 6786.2500 261.0096
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 1 1.000000 507.0000 507.0000
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 4 4.000000 661.6600 165.4150
OCTH-97167-OT EVAL HIGH COMPLEXITY 10 10.000000 470.5000 47.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 2 2.000000 87.1000 43.5500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 10 10.000000 510.5000 51.0500
Subtotal (Total Children Is Unduplicated) 125 174.000000 21504.1900 123.5873
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EI Services,Class #03
OCCT-97530-OT SESSION BY LICENSED OT 19 98.000000 6847.4000 69.8714
OCCT-97530HM-OT SESSION BY OT ASST 5 24.500000 1401.4000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 9 27.500000 1849.0900 67.2396
PHY-97110HM-PT SESSION BY PT ASST 5 41.500000 2372.1400 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 14 71.500000 5107.9600 71.4400
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 2 4.000000 228.8000 57.2000
Subtotal (Total Children Is Unduplicated) 43 267.000000 17806.7900 66.6921
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Total 441.000000 39310.9800 89.1405
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Number of Children (Unduplicated) With at Least One Service 148
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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 63 98.000000 10301.2900 10301.2900
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 2 7.500000 535.8000 0.0000
T 0 0.000000 0.0000 0.0000
113 121.500000 14220.2500 0.0000
Other 86 214.000000 14253.6400 142.9000
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Total 264 441.000000 39310.9800 10444.1900