CMS/EIP Fiscal Report Center: 09
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 5 8.500000 592.5000 69.7059
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 6 10.500000 591.5000 56.3333
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 11 20.000000 1500.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 3 5.500000 305.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 69 105.500000 7477.5000 70.8768
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 25 37.000000 2660.0000 71.8919
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 49 77.000000 5592.9600 72.6358
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 58 101.500000 5298.5500 52.2025
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 68 107.000000 7263.0000 67.8785
OCTH-97166-OT EVAL MODERATE COMPLEXITY 1 1.000000 51.0500 51.0500
SPCH-92521-EVAL OF SPEECH FLUENCY 1 1.000000 51.0500 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 4 4.000000 189.2000 47.3000
Subtotal (Total Children Is Unduplicated) 173 480.500000 31722.5600 66.0199
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EI Services,Class #03
OCCT-97530-OT SESSION BY LICENSED OT 28 170.500000 10630.2700 62.3476
PHY-97110-PT SESSION BY LICENSED PT 42 299.500000 20682.7700 69.0577
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 96 713.250000 47265.0600 66.2672
Subtotal (Total Children Is Unduplicated) 152 1183.250000 78578.1000 66.4087
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Total 1663.750000 110300.6600 66.2964
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Number of Children (Unduplicated) With at Least One Service 306
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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 0 0.000000 0.0000 0.0000
P 557 941.250000 59549.9900 59705.6700
D 4 4.000000 285.7600 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 1 1.000000 71.4400 55.6900
240 617.500000 42893.4700 0.0000
Other 63 100.000000 7500.0000 0.0000
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Total 865 1663.750000 110300.6600 59761.3600