CMS/EIP Fiscal Report Center: 09
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
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 2 3.500000 152.6100 43.6029
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 2 3.000000 225.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 5 9.000000 675.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 2.000000 111.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 77 120.000000 7971.7200 66.4310
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 35 57.000000 3717.9500 65.2272
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 28 46.000000 3193.5600 69.4252
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 72 124.500000 6101.3800 49.0071
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 66 103.500000 7069.4700 68.3041
OCTH-97166-OT EVAL MODERATE COMPLEXITY 3 3.000000 153.1500 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 9 9.000000 389.4500 43.2722
SPCH-92524-BEHAV & QUAL ANALYSIS OF VOICE AND RES 1 1.000000 51.0500 51.0500
SPCH-92610-EVAL OF ORAL,PHARYNGEAL SWALLOWING FUNC 2 2.000000 97.8800 48.9400
Subtotal (Total Children Is Unduplicated) 194 485.500000 30059.2200 61.9139
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1 3.000000 150.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 36 253.500000 16494.4700 65.0669
PHY-97110-PT SESSION BY LICENSED PT 53 446.000000 29565.8400 66.2911
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 92 578.500000 37098.0500 64.1280
Subtotal (Total Children Is Unduplicated) 164 1281.000000 83308.3600 65.0338
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Total 1766.500000 113367.5800 64.1764
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Number of Children (Unduplicated) With at Least One Service 332
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Center 09
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 1 1.500000 112.5000 0.0000
P 398 717.500000 40642.7300 40764.5400
D 11 11.000000 785.8400 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
481 987.000000 68114.0100 0.0000
Other 30 49.500000 3712.5000 0.0000
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Total 921 1766.500000 113367.5800 40764.5400