CMS/EIP Fiscal Report Center: 03
Services beginning 04/01/2020 ending 06/30/2020 Date of Report:07/21/2020 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-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 1 1.000000 75.0000 75.0000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 1 1.000000 55.5000 55.5000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 17 28.500000 2137.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 10 16.500000 1237.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 1 2.000000 111.0000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 3 5.500000 305.2500 55.5000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 3 3.500000 262.5000 75.0000
OCTF-97168-OT RE-EVAL EST PLAN CARE 1 1.000000 51.0500 51.0500
OCTH-97165-OT EVAL LOW COMPLEXITY 2 2.000000 52.3700 26.1850
PSTH-97161GT-PT EVAL LOW COMPLEXITY 1 1.000000 51.0500 51.0500
SPCH-92523GT-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 2 2.000000 102.1000 51.0500
Subtotal (Total Children Is Unduplicated) 32 64.000000 4440.8200 69.3878
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1 1.000000 50.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 9 21.500000 1075.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 4 6.750000 281.4300 41.6933
OCCT-97530GT-OT SESSION BY LICENSED OT 2 2.750000 196.4600 71.4400
PHY-97110-PT SESSION BY LICENSED PT 1 1.000000 71.4400 71.4400
PHY-97110GT-PT SESSION BY LICENSED PT 5 8.750000 625.1000 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 3 4.500000 171.4800 38.1067
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 13 25.750000 1839.5800 71.4400
Subtotal (Total Children Is Unduplicated) 35 72.000000 4310.4900 59.8679
-----------------------------------------------------------------------------------------------------------------------
Total 136.000000 8751.3100 64.3479
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 60
-----------------------------------------------------------------------------------------------------------------------
Center 03
Flag Claims Units Chgs Paid
---------------------------------------------------------
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 2 2.000000 17.0400 17.0400
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
121 134.000000 8734.2700 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 123 136.000000 8751.3100 17.0400