CMS/EIP Fiscal Report Center: 02
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-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 2 4.000000 300.0000 75.0000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 16 32.000000 2400.0000 75.0000
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 2 2.000000 102.1000 51.0500
Subtotal (Total Children Is Unduplicated) 20 38.000000 2802.1000 73.7395
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EI Services,Class #03
OCCT-97530-OT SESSION BY LICENSED OT 13 45.250000 3232.6600 71.4400
PHY-97110-PT SESSION BY LICENSED PT 11 49.750000 2623.0100 52.7238
SENS-V5264-EARMOLD 1 1.000000 18.0000 18.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 40 290.250000 20192.1400 69.5681
Subtotal (Total Children Is Unduplicated) 60 386.250000 26065.8100 67.4843
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Total 424.250000 28867.9100 68.0446
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Number of Children (Unduplicated) With at Least One Service 73
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Center 02
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 0 0.000000 0.0000 0.0000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 408 378.750000 25749.7200 25331.5100
47 45.500000 3118.1900 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 455 424.250000 28867.9100 25331.5100