CMS/EIP Fiscal Report Center: 01
Services beginning 10/01/2019 ending 12/31/2019 Date of Report:02/01/2020 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 3 4.500000 337.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 4 8.500000 637.5000 75.0000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 33 52.000000 3419.9300 65.7679
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 3 4.500000 337.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 36 57.000000 3083.5000 54.0965
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 36 62.500000 4687.5000 75.0000
OCTH-97165-OT EVAL LOW COMPLEXITY 1 1.000000 51.0500 51.0500
OCTH-97166-OT EVAL MODERATE COMPLEXITY 1 1.000000 51.0500 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 1 1.000000 51.0500 51.0500
SPCH-92522-EVAL OF SPCH SOUND PROD 1 1.000000 10.5500 10.5500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 2 3.000000 153.1500 51.0500
Subtotal (Total Children Is Unduplicated) 79 196.000000 12820.2800 65.4096
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 3 3.000000 1710.1600 570.0533
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 345 2175.250000 108758.9400 49.9984
INTR-T1013-INTERPRETER 2 4.500000 225.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 27 198.750000 13728.6500 69.0750
PHY-97110-PT SESSION BY LICENSED PT 39 197.250000 13110.2800 66.4653
PHY-97110HM-PT SESSION BY PT ASST 1 2.000000 114.3200 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 96 527.500000 33800.2600 64.0763
SPL-92508-GROUP SPL SESSION PER CHILD 2 10.000000 138.8000 13.8800
Subtotal (Total Children Is Unduplicated) 449 3118.250000 171586.4100 55.0265
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Total 3314.250000 184406.6900 55.6405
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Number of Children (Unduplicated) With at Least One Service 494
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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 2547 2562.500000 136740.0200 136740.0200
D 24 24.000000 1353.2500 0.0000
S 27 28.000000 1473.2300 0.0000
H 334 347.750000 23893.8600 0.0000
T 104 102.500000 6069.3700 6069.3700
231 237.500000 13976.9600 0.0000
Other 9 12.000000 900.0000 0.0000
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Total 3276 3314.250000 184406.6900 142809.3900