CMS/EIP Fiscal Report Center: 06
Services beginning 10/01/2020 ending 12/31/2020 Date of Report:01/23/2021 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 1.500000 112.5000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 2.000000 111.0000 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 1 1.500000 83.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 6 10.500000 787.5000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 64 101.500000 7573.5000 74.6158
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 2 4.000000 300.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 22 34.500000 2587.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 3 4.500000 337.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 30 48.000000 3600.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 5 10.000000 555.0000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 55 88.000000 4923.0000 55.9432
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 2.000000 150.0000 75.0000
Subtotal (Total Children Is Unduplicated) 96 310.000000 21270.7500 68.6153
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EI Services,Class #03
AUD-92593TS-AUDIOLOGY SERVICES (Biaural) 1 1.000000 50.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 6 36.000000 1800.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 2 4.000000 200.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 31 131.000000 8921.4500 68.1027
OCCT-97530GT-OT SESSION BY LICENSED OT 10 39.000000 2747.7800 70.4559
OCCT-97530HM-OT SESSION BY OT ASST 5 4.750000 271.7000 57.2000
OCCT-97530HMGT-OT SESSION BY OT ASST 5 7.750000 443.3000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 41 171.000000 11647.1400 68.1119
PHY-97110GT-PT SESSION BY LICENSED PT 18 34.000000 2334.2000 68.6529
PHY-97110HM-PT SESSION BY PT ASST 2 4.500000 257.2200 57.1600
PHY-97110HMGT-PT SESSION BY LICENSED PT ASST 1 0.500000 28.5800 57.1600
SENS-V5264-EARMOLD 1 2.000000 36.0000 18.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 110 407.000000 26991.1000 66.3172
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 49 156.500000 10998.6300 70.2788
SPL-92508-GROUP SPL SESSION PER CHILD 1 12.500000 138.8000 11.1040
Subtotal (Total Children Is Unduplicated) 218 1011.500000 66865.9000 66.1057
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Total 1321.500000 88136.6500 66.6944
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Number of Children (Unduplicated) With at Least One Service 299
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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 982 556.750000 36442.2400 36442.2400
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
987 764.750000 51694.4100 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 1969 1321.500000 88136.6500 36442.2400