CMS/EIP Fiscal Report Center: 02
Services beginning 01/01/2020 ending 03/31/2020 Date of Report:05/15/2020 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
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 25 49.500000 3637.5000 73.4848
PSTH-97161-PT EVAL LOW COMPLEXITY 1 1.000000 51.0500 51.0500
PSTH-97162-PT EVAL MODERATE COMPLEXITY 1 1.000000 51.0500 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 2 2.000000 90.1000 45.0500
Subtotal (Total Children Is Unduplicated) 28 53.500000 3829.7000 71.5832
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1 2.000000 100.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 13 47.750000 3401.2600 71.2306
PHY-97110-PT SESSION BY LICENSED PT 13 50.250000 3422.1300 68.1021
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 29 145.250000 10376.6600 71.4400
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 4 5.500000 392.9200 71.4400
Subtotal (Total Children Is Unduplicated) 51 250.750000 17692.9700 70.5602
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Total 304.250000 21522.6700 70.7401
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Number of Children (Unduplicated) With at Least One Service 72
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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 302 289.000000 20433.2100 20411.7700
20 15.250000 1089.4600 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 322 304.250000 21522.6700 20411.7700