CMS/EIP Fiscal Report Center: 01
Services beginning 07/01/2019 ending 09/30/2019 Date of Report:11/04/2019 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 3 2.500000 92.5000 37.0000
Subtotal (Total Children Is Unduplicated) 3 2.500000 92.5000 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 4 6.500000 487.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 12 30.000000 2250.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 7 16.500000 915.7500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 46 70.000000 4916.3600 70.2337
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 4 5.000000 375.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 3 4.000000 300.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 86 134.000000 7437.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 74 135.000000 10054.0700 74.4746
OCTH-97165-OT EVAL LOW COMPLEXITY 1 1.000000 29.5600 29.5600
PSTH-97162-PT EVAL MODERATE COMPLEXITY 1 1.000000 51.0500 51.0500
SPCH-92522-EVAL OF SPCH SOUND PROD 1 1.000000 51.0500 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 3 3.000000 153.1500 51.0500
SPCH-92610-EVAL OF ORAL,PHARYNGEAL SWALLOWING FUNC 1 1.000000 48.9400 48.9400
Subtotal (Total Children Is Unduplicated) 147 408.000000 27069.4300 66.3466
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 1 1.000000 103.0600 103.0600
AUDE-V5160-DISPENSING FEE BINAURAL 1 1.000000 59.0000 59.0000
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 1 2.000000 100.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 362 2352.000000 117450.0000 49.9362
INTR-T1013-INTERPRETER 1 3.000000 150.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 38 240.750000 16290.1800 67.6643
OCCT-97530HM-OT SESSION BY OT ASST 1 3.750000 214.5000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 33 187.000000 11820.4500 63.2110
PHY-97110HM-PT SESSION BY PT ASST 1 10.000000 571.6000 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 104 524.750000 33642.8200 64.1121
SPL-92508-GROUP SPL SESSION PER CHILD 3 13.000000 180.4400 13.8800
Subtotal (Total Children Is Unduplicated) 458 3338.250000 180582.0500 54.0948
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Total 3748.750000 207743.9800 55.4169
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Number of Children (Unduplicated) With at Least One Service 543
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Center 01
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 2739 2771.750000 146008.3400 146008.3400
D 36 36.000000 1922.4400 0.0000
S 260 274.500000 17223.6900 0.0000
H 348 385.750000 25932.8300 0.0000
T 123 117.000000 6748.7000 6748.7000
124 128.750000 7497.4800 0.0000
Other 22 35.000000 2410.5000 0.0000
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Total 3652 3748.750000 207743.9800 152757.0400