CMS/EIP Fiscal Report Center: 06
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
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 2 1.000000 37.0000 37.0000
Subtotal (Total Children Is Unduplicated) 2 1.000000 37.0000 37.0000
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 4 6.500000 487.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 1.500000 112.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 2 3.000000 225.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 5 8.000000 444.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 136 208.500000 15632.8100 74.9775
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 56 84.000000 6300.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 48 69.500000 5212.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 128 202.000000 11211.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 4 5.500000 412.5000 75.0000
Subtotal (Total Children Is Unduplicated) 192 588.500000 40037.8100 68.0337
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EI Services,Class #03
AUDE-V5160-DISPENSING FEE BINAURAL 1 1.000000 230.0000 230.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 8 46.000000 2300.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 2 2.000000 100.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 60 184.500000 12351.8300 66.9476
OCCT-97530GT-OT SESSION BY LICENSED OT 7 5.500000 392.9200 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 14 39.000000 2187.8400 56.0985
OCCT-97530HMGT-OT SESSION BY OT ASST 4 2.500000 114.4000 45.7600
PHY-97110-PT SESSION BY LICENSED PT 52 218.000000 14702.1500 67.4411
PHY-97110GT-PT SESSION BY LICENSED PT 7 4.500000 321.4800 71.4400
PHY-97110HM-PT SESSION BY PT ASST 2 2.000000 114.3200 57.1600
SENS-V5140-BEHIND EAR BINAURAL HEARING AID 1 1.000000 456.0000 456.0000
SENS-V5264-EARMOLD 1 2.000000 36.0000 18.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 135 562.000000 39096.8000 69.5673
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 38 34.750000 2472.5400 71.1522
SPL-92508-GROUP SPL SESSION PER CHILD 1 1.500000 107.1600 71.4400
Subtotal (Total Children Is Unduplicated) 239 1106.250000 74983.4400 67.7816
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Total 1695.750000 115058.2500 67.8510
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Number of Children (Unduplicated) With at Least One Service 404
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Center 06
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 1410 811.750000 55348.5100 55348.5100
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
932 884.000000 59709.7400 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 2342 1695.750000 115058.2500 55348.5100