CMS/EIP Fiscal Report Center: 57
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 6 6.500000 487.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 2 3.000000 225.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 7 11.500000 638.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 127 140.000000 10500.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 122 156.000000 8658.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 14 15.500000 1162.5000 75.0000
OCTH-97167-OT EVAL HIGH COMPLEXITY 2 2.000000 102.1000 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 2 2.000000 102.1000 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 10 10.000000 510.5000 51.0500
Subtotal (Total Children Is Unduplicated) 149 346.500000 22385.9500 64.6059
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 309 2384.000000 119200.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 8 26.000000 1857.4400 71.4400
PHY-97110-PT SESSION BY LICENSED PT 25 52.000000 3714.8800 71.4400
PHY-97110HM-PT SESSION BY PT ASST 1 4.000000 228.6400 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 33 165.500000 11812.6000 71.3752
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 2 15.000000 858.0000 57.2000
Subtotal (Total Children Is Unduplicated) 347 2646.500000 137671.5600 52.0202
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Total 2993.000000 160057.5100 53.4773
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Number of Children (Unduplicated) With at Least One Service 427
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Center 57
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 23 13.000000 908.3300 908.3300
D 0 0.000000 0.0000 0.0000
S 2 11.000000 550.0000 550.0000
H 0 0.000000 0.0000 0.0000
T 704 2347.000000 118257.8200 118257.8200
447 622.000000 40341.3600 19741.0200
Other 0 0.000000 0.0000 0.0000
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Total 1176 2993.000000 160057.5100 139457.1700