CMS/EIP Fiscal Report Center: 03
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
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 2 3.500000 262.5000 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 15 26.500000 1987.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 8 13.500000 1012.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 8 15.500000 860.2500 55.5000
OCTF-97168-OT RE-EVAL EST PLAN CARE 1 1.000000 51.0500 51.0500
SCREEN-T1023-SCREENING 6 6.000000 300.0000 50.0000
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 1 1.000000 51.0500 51.0500
Subtotal (Total Children Is Unduplicated) 25 68.500000 4608.1000 67.2715
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 5 7.750000 387.5000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 6 6.000000 300.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 7 28.000000 1671.5000 59.6964
PHY-97110-PT SESSION BY LICENSED PT 8 20.000000 1428.8000 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 12 51.250000 3442.1600 67.1641
Subtotal (Total Children Is Unduplicated) 36 113.000000 7229.9600 63.9819
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Total 181.500000 11838.0600 65.2235
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Number of Children (Unduplicated) With at Least One Service 57
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Center 03
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 18 17.500000 1116.6400 1116.6400
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 4 4.000000 285.7600 285.7600
T 0 0.000000 0.0000 0.0000
138 160.000000 10435.6600 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 160 181.500000 11838.0600 1402.4000