CMS/EIP Fiscal Report Center: 06
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 1.500000 112.5000 75.0000
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 1 2.000000 150.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 1.500000 83.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 53 78.000000 5850.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 32 46.500000 3487.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 50 76.000000 5700.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 124 186.000000 10323.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 79 117.500000 8812.5000 75.0000
Subtotal (Total Children Is Unduplicated) 173 511.000000 34668.7500 67.8449
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 1 1.000000 2176.5000 2176.5000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 8 11.000000 550.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 48 135.000000 9270.2600 68.6686
OCCT-97530HM-OT SESSION BY OT ASST 17 68.500000 3939.3200 57.5083
PHY-97110-PT SESSION BY LICENSED PT 48 203.000000 13523.1600 66.6166
PHY-97110HM-PT SESSION BY PT ASST 1 1.000000 71.4400 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 121 542.750000 36777.9700 67.7623
Subtotal (Total Children Is Unduplicated) 211 962.250000 66308.6500 68.9100
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Total 1473.250000 100977.4000 68.5406
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Number of Children (Unduplicated) With at Least One Service 351
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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 645 379.250000 25257.2400 25257.2400
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
1418 1094.000000 75720.1600 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 2063 1473.250000 100977.4000 25257.2400