CMS/EIP Fiscal Report Center: 06
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
Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 2.000000 150.0000 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 136 205.500000 15412.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 53 79.500000 5962.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 57 84.000000 6300.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 119 192.500000 10683.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 1.500000 112.5000 75.0000
Subtotal (Total Children Is Unduplicated) 184 567.000000 38732.2500 68.3108
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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 37 115.750000 8125.1100 70.1953
OCCT-97530HM-OT SESSION BY OT ASST 20 61.500000 3482.9000 56.6325
PHY-97110-PT SESSION BY LICENSED PT 45 187.500000 12342.0200 65.8241
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 133 620.250000 41925.3200 67.5942
Subtotal (Total Children Is Unduplicated) 201 1026.000000 67925.3500 66.2040
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Total 1593.000000 106657.6000 66.9539
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Number of Children (Unduplicated) With at Least One Service 365
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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 856 525.750000 35179.0100 35179.0100
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
1224 1067.250000 71478.5900 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 2080 1593.000000 106657.6000 35179.0100