CMS/EIP Fiscal Report Center: 02
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 1 2.000000 150.0000 75.0000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 20 38.500000 2887.5000 75.0000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 2.000000 150.0000 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-97162-PT EVAL MODERATE COMPLEXITY 2 2.000000 54.3600 27.1800
PSTH-97163-PT EVAL HIGH COMPLEXITY 1 1.000000 51.0500 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 1 1.000000 51.0500 51.0500
Subtotal (Total Children Is Unduplicated) 26 48.500000 3446.0600 71.0528
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 2 2.000000 254.0000 127.0000
OCCT-97530-OT SESSION BY LICENSED OT 13 72.000000 4935.5200 68.5489
PHY-97110-PT SESSION BY LICENSED PT 17 55.250000 3453.3000 62.5032
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 31 207.500000 14795.2200 71.3023
Subtotal (Total Children Is Unduplicated) 54 336.750000 23438.0400 69.6007
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Total 385.250000 26884.1000 69.7835
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Number of Children (Unduplicated) With at Least One Service 74
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Center 02
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 0 0.000000 0.0000 0.0000
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 438 382.250000 26721.6200 26721.6200
4 3.000000 162.4800 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 442 385.250000 26884.1000 26721.6200