CMS/EIP Fiscal Report Center: 06
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
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 1 0.500000 18.5000 37.0000
Subtotal (Total Children Is Unduplicated) 1 0.500000 18.5000 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 2 3.000000 225.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 2 3.000000 166.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 89 141.000000 9975.0000 70.7447
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 53 89.000000 6675.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 2 2.500000 187.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 124 202.500000 10794.7500 53.3074
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 38 58.000000 4350.0000 75.0000
Subtotal (Total Children Is Unduplicated) 155 499.000000 32373.7500 64.8773
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EI Services,Class #03
AUD-92593TS-AUDIOLOGY SERVICES (Biaural) 1 1.000000 50.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 295 2303.250000 115162.5000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 70 249.500000 17283.1900 69.2713
OCCT-97530HM-OT SESSION BY OT ASST 27 119.250000 6797.7400 57.0041
PHY-97110-PT SESSION BY LICENSED PT 44 220.000000 13685.9300 62.2088
PHY-97110HM-PT SESSION BY PT ASST 1 0.500000 3.5800 7.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 195 1038.250000 68769.9100 66.2364
Subtotal (Total Children Is Unduplicated) 519 3931.750000 221752.8500 56.4005
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Total 4431.250000 254145.1000 57.3529
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Number of Children (Unduplicated) With at Least One Service 603
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Center 06
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 2590 2176.750000 119857.5300 119857.5300
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 0 0.000000 0.0000 0.0000
2667 2254.500000 134287.5700 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 5257 4431.250000 254145.1000 119857.5300