CMS/EIP Fiscal Report Center: 55
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
EVAL-96111-DEVELOPMENTAL EVALUATION 1 2.000000 100.0000 50.0000
EXIT-EXIT-EXIT ASSESSMENT 1 1.000000 50.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 3 3.325066 249.3799 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 3 4.507866 338.0900 75.0000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 67 100.238669 7517.9001 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 43 65.554136 4916.5603 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 4 8.000000 600.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 3 5.500000 305.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 12 20.984534 1573.8400 75.0000
OCTF-97168-OT RE-EVAL EST PLAN CARE 6 6.000000 306.3000 51.0500
OCTH-97166-OT EVAL MODERATE COMPLEXITY 1 1.000000 51.0500 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 6 5.489716 280.2500 51.0500
PSTF-97164-PT RE-EVAL EST PLAN CARE 3 3.000000 153.1500 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 7 5.825465 297.3900 51.0500
Subtotal (Total Children Is Unduplicated) 108 234.425452 16841.2603 71.8406
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EI Services,Class #03
CONIP-CONIP-CONSULT, ITDS PHONE 2 2.000000 50.0000 25.0000
CONSP-CONSP-CONSULT, SLP, PHONE 3 2.500000 62.5000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 10 32.900000 1645.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 34 186.182400 13300.8700 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 42 195.011886 11154.6800 57.2000
PHY-97110-PT SESSION BY LICENSED PT 23 149.036953 10647.2000 71.4400
PHY-97110HM-PT SESSION BY PT ASST 18 101.668298 5811.3600 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 88 550.855391 39353.1100 71.4400
Subtotal (Total Children Is Unduplicated) 162 1220.154928 82024.7200 67.2248
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Total 1454.580380 98865.9803 67.9687
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Number of Children (Unduplicated) With at Least One Service 236
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Center 55
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 725 703.520784 47764.7800 47764.7800
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 8 16.000000 1200.0000 0.0000
T 0 0.000000 0.0000 0.0000
857 735.059596 49901.2003 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 1590 1454.580380 98865.9803 47764.7800