CMS/EIP Fiscal Report Center: 04
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:Part C (excluding not eligible)
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Screening, Eval, and Assessment,Class #02
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 1.500000 112.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 6 7.500000 562.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 1.000000 55.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 2 1.500000 112.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 3 2.500000 187.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 6 6.000000 333.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 59 55.500000 4382.8100 78.9695
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 8 8.000000 2432.0000 304.0000
MED-99204-OUTPATIENT VISIT, NEW, 45 MINS 2 2.000000 1014.0000 507.0000
OCTH-97166-OT EVAL MODERATE COMPLEXITY 4 4.000000 204.2000 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 5 5.000000 255.2500 51.0500
PSTH-97162-PT EVAL MODERATE COMPLEXITY 5 5.000000 255.2500 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 9 9.000000 459.4500 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 4 4.000000 204.2000 51.0500
SPCH-92524-BEHAV & QUAL ANALYSIS OF VOICE AND RES 5 5.000000 255.2500 51.0500
SPCH-92610-EVAL OF ORAL,PHARYNGEAL SWALLOWING FUNC 1 1.000000 48.9400 48.9400
Subtotal (Total Children Is Unduplicated) 91 118.500000 10874.8500 91.7709
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 4 41.000000 2050.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 17 82.500000 5893.8000 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 16 75.500000 4316.6800 57.1746
PHY-97110-PT SESSION BY LICENSED PT 18 95.000000 6565.3600 69.1091
PHY-97110HM-PT SESSION BY PT ASST 4 12.500000 714.5000 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 19 97.000000 6679.6400 68.8623
SPL-92508-GROUP SPL SESSION PER CHILD 1 4.000000 55.5200 13.8800
Subtotal (Total Children Is Unduplicated) 54 407.500000 26275.5000 64.4798
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Total 526.000000 37150.3500 70.6280
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Number of Children (Unduplicated) With at Least One Service 122
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Center 04
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 108 252.000000 16461.5700 11451.5800
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 10 44.000000 2221.6000 0.0000
T 0 0.000000 0.0000 0.0000
92 86.500000 8949.0900 0.0000
Other 67 143.500000 9518.0900 0.0000
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Total 277 526.000000 37150.3500 11451.5800