CMS/EIP Fiscal Report Center: 09
Services beginning 10/01/2019 ending 12/31/2019 Date of Report:02/01/2020 Page: 1
List order: No List
Agency Filter:EXT
Payclass Filters:MED
Eligibility Filter:Part C (excluding not eligible)
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 2 4.000000 300.0000 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 1.500000 112.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 2 3.500000 262.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 2.000000 111.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 23 40.000000 3000.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 18 35.500000 2662.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 48 83.500000 6223.5000 74.5329
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 18 30.500000 1692.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 37 59.000000 4425.0000 75.0000
Subtotal (Total Children Is Unduplicated) 138 261.500000 18939.7500 72.4273
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 778 5341.000000 267004.0000 49.9914
OCCT-97530-OT SESSION BY LICENSED OT 53 338.000000 24146.7200 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 1 5.000000 286.0000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 86 619.000000 44221.3600 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 159 1262.500000 90193.0000 71.4400
Subtotal (Total Children Is Unduplicated) 949 7565.500000 425851.0800 56.2886
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Total 7827.000000 444790.8300 56.8278
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Number of Children (Unduplicated) With at Least One Service 1020
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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 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 0 0.000000 0.0000 0.0000
2420 7578.500000 426826.0800 0.0000
Other 143 248.500000 17964.7500 0.0000
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Total 2563 7827.000000 444790.8300 0.0000