CMS/EIP Fiscal Report Center: 09
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 2 3.500000 262.5000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 3 5.000000 375.0000 75.0000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 5 10.000000 374.6300 37.4630
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 22 42.000000 3005.0000 71.5476
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 22 42.000000 3105.0000 73.9286
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 3 5.500000 412.5000 75.0000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 72 140.500000 7097.2900 50.5145
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 13 25.000000 1875.0000 75.0000
OCTH-97166GT-OT EVAL MODERATE COMPLEXITY 1 1.000000 51.0500 51.0500
OCTH-97166TLGT-OT EVAL MODERATE COMPLEXITY 2 2.000000 102.1000 51.0500
SPCH-92523TLGT-EVAL OF SPCH SOUND PROD; EVAL LANG COM 1 1.000000 51.0500 51.0500
Subtotal (Total Children Is Unduplicated) 107 279.500000 16861.1200 60.3260
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EI Services,Class #03
OCCT-97530-OT SESSION BY LICENSED OT 16 101.000000 6368.4500 63.0540
OCCT-97530GT-OT SESSION BY LICENSED OT 3 16.000000 1143.0400 71.4400
OCCT-97530TLGT-OT SESSION BY LICENSED OT 6 40.500000 2893.3200 71.4400
PHY-97110-PT SESSION BY LICENSED PT 25 160.000000 10416.8500 65.1053
PHY-97110GT-PT SESSION BY LICENSED PT 6 28.750000 2053.9000 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 57 384.500000 26058.9100 67.7735
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 19 111.000000 7567.6100 68.1767
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 5 27.000000 1928.8800 71.4400
Subtotal (Total Children Is Unduplicated) 112 868.750000 58430.9600 67.2587
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Total 1148.250000 75292.0800 65.5712
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Number of Children (Unduplicated) With at Least One Service 203
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Center 09
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 202 352.750000 21104.3200 21568.1800
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 93 199.000000 11922.3500 11235.3500
204 571.000000 40391.9100 0.0000
Other 13 25.500000 1873.5000 0.0000
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Total 512 1148.250000 75292.0800 32803.5300