CMS/EIP Fiscal Report Center: 01
Services beginning 10/01/2018 ending 12/31/2018 Date of Report:02/06/2019 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
ASTE-ASTE-ASSISTIVE TECHNOLOGY EVAL 1 1.000000 48.5000 48.5000
AUDE-92586-AUD EVOKED RESPONSE (LIMITED) 1 2.000000 59.0600 29.5300
EVAL-96111-DEVELOPMENTAL EVALUATION 1 1.500000 75.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 3 6.000000 286.0200 47.6700
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 5 12.500000 937.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 5 12.500000 643.8000 51.5040
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 50 89.000000 5786.5700 65.0176
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 99 171.000000 9116.5900 53.3134
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 93 180.000000 13236.0000 73.5333
OCTF-97168-OT RE-EVAL EST PLAN CARE 1 1.000000 51.0500 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 1 1.000000 51.0500 51.0500
PSTH-97161-PT EVAL LOW COMPLEXITY 1 2.000000 58.2000 29.1000
PSTH-97163-PT EVAL HIGH COMPLEXITY 1 1.000000 51.0500 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 2 2.000000 62.1000 31.0500
Subtotal (Total Children Is Unduplicated) 160 482.500000 30462.4900 63.1347
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 1 1.000000 50.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 341 2173.750000 108425.0000 49.8792
INTR-T1013-INTERPRETER 6 12.500000 625.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 24 192.500000 11987.3100 62.2717
PHY-97110-PT SESSION BY LICENSED PT 41 302.500000 19761.4900 65.3272
PHY-97110HM-PT SESSION BY PT ASST 1 2.750000 175.0400 63.6509
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 78 461.250000 27427.0800 59.4625
SPL-92508-GROUP SPL SESSION PER CHILD 1 2.000000 27.7600 13.8800
Subtotal (Total Children Is Unduplicated) 421 3148.250000 168478.6800 53.5150
-----------------------------------------------------------------------------------------------------------------------
Total 3630.750000 198941.1700 54.7934
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 509
-----------------------------------------------------------------------------------------------------------------------
Center 01
Flag Claims Units Chgs Paid
---------------------------------------------------------
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 2744 2829.000000 151672.2600 151672.2600
D 70 69.250000 3256.6800 0.0000
S 71 76.000000 4072.4000 0.0000
H 156 199.500000 14466.4100 0.0000
T 238 241.000000 12946.8000 12885.3600
143 165.500000 9392.1700 0.0000
Other 38 50.500000 3134.4500 450.0000
---------------------------------------------------------
Total 3460 3630.750000 198941.1700 165007.6200