CMS/EIP Fiscal Report Center: 55
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
EVAL-96111-DEVELOPMENTAL EVALUATION 4 8.000000 400.0000 50.0000
EXIT-EXIT-EXIT ASSESSMENT 1 1.000000 50.0000 50.0000
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 49 85.821201 6436.5900 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 42 88.550533 6641.2900 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 12 24.468133 1835.1100 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 2 4.000000 222.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 2 4.000000 300.0000 75.0000
OCTH-97167-OT EVAL HIGH COMPLEXITY 5 4.979432 254.2000 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 1 1.000000 51.0500 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 8 12.000000 612.6000 51.0500
Subtotal (Total Children Is Unduplicated) 83 235.819299 16952.8400 71.8891
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EI Services,Class #03
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 24 26.000000 1300.0000 50.0000
CONIP-CONIP-CONSULT, ITDS PHONE 10 6.000000 150.0000 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 4 5.000000 250.0000 50.0000
CONOP-CONOP-CONSULT, OT, PHONE 5 6.000000 150.0000 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 23 23.000000 1150.0000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 10 6.500000 162.5000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 40 147.600000 7380.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 37 185.683375 13265.2200 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 43 229.793528 13144.1900 57.2000
PHY-97110-PT SESSION BY LICENSED PT 21 134.484582 9607.5785 71.4400
PHY-97110HM-PT SESSION BY PT ASST 16 103.305455 5904.9400 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 91 544.810891 38878.4100 71.3613
Subtotal (Total Children Is Unduplicated) 227 1418.177831 91342.8385 64.4086
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Total 1653.997130 108295.6785 65.4751
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Number of Children (Unduplicated) With at Least One Service 284
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Center 55
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 559 561.000000 37547.5100 37547.5100
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 13 26.000000 1950.0000 0.0000
T 0 0.000000 0.0000 0.0000
1156 1066.997130 68798.1685 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 1728 1653.997130 108295.6785 37547.5100