CMS/EIP Fiscal Report Center: 02
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
BEHV-H2014BA-BEHAVIOR ANALYSIS-ASSOCIATE 2 12.000000 576.8800 48.0733
EXIT-EXIT-EXIT ASSESSMENT 1 1.000000 50.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 2.000000 150.0000 75.0000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 19 35.500000 2560.9600 72.1397
OCTH-97165-OT EVAL LOW COMPLEXITY 1 1.000000 51.0500 51.0500
PSTF-97164-PT RE-EVAL EST PLAN CARE 2 2.000000 73.6600 36.8300
PSTH-97162-PT EVAL MODERATE COMPLEXITY 1 1.000000 51.0500 51.0500
SPCH-92521-EVAL OF SPEECH FLUENCY 2 2.000000 102.1000 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 6 6.000000 306.3000 51.0500
Subtotal (Total Children Is Unduplicated) 31 62.500000 3922.0000 62.7520
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EI Services,Class #03
COUN-H2019HR-INDIVIDUAL/FAMILY THERAPY 1 2.000000 146.6400 73.3200
OCCT-97530-OT SESSION BY LICENSED OT 12 56.000000 3467.6600 61.9225
PHY-97110-PT SESSION BY LICENSED PT 11 57.500000 3180.2700 55.3090
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 34 228.500000 16146.1400 70.6614
Subtotal (Total Children Is Unduplicated) 48 344.000000 22940.7100 66.6881
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Total 406.500000 26862.7100 66.0829
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Number of Children (Unduplicated) With at Least One Service 69
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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 455 398.500000 26352.3600 25565.2300
13 8.000000 510.3500 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 468 406.500000 26862.7100 25565.2300