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
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-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 2 3.500000 194.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 61 99.500000 6712.3500 67.4608
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 28 46.000000 3253.6700 70.7320
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 30 46.000000 3415.0000 74.2391
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 70 123.500000 6694.2500 54.2045
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 64 106.000000 7454.4000 70.3245
OCTH-97166-OT EVAL MODERATE COMPLEXITY 2 2.000000 102.1000 51.0500
PSTH-97162-PT EVAL MODERATE COMPLEXITY 1 1.000000 51.0500 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 9 9.000000 459.4500 51.0500
Subtotal (Total Children Is Unduplicated) 161 438.000000 28449.0200 64.9521
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 1 1.000000 351.7400 351.7400
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 2 9.000000 450.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 33 219.500000 14883.7200 67.8074
OCCT-97530HM-OT SESSION BY OT ASST 1 4.000000 58.5200 14.6300
PHY-97110-PT SESSION BY LICENSED PT 38 294.500000 19676.3900 66.8129
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 95 673.250000 44704.5800 66.4012
Subtotal (Total Children Is Unduplicated) 155 1201.250000 80124.9500 66.7013
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Total 1639.250000 108573.9700 66.2339
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Number of Children (Unduplicated) With at Least One Service 297
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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 4 4.000000 185.7600 0.0000
P 567 969.750000 61285.9000 62060.6600
D 9 9.000000 642.9600 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
226 558.500000 39138.6000 0.0000
Other 61 98.000000 7320.7500 0.0000
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Total 867 1639.250000 108573.9700 62060.6600