CMS/EIP Fiscal Report Center: 05
Services beginning 07/01/2019 ending 09/30/2019 Date of Report:11/04/2019 Page: 1
List order: No List
Payclass Filters:TPIN
Eligibility Filter:Part C (excluding not eligible)
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Screening, Eval, and Assessment,Class #02
PSTH-97163-PT EVAL HIGH COMPLEXITY 3 3.000000 153.1500 51.0500
SPCH-92521-EVAL OF SPEECH FLUENCY 1 1.000000 51.0500 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 1 1.000000 51.0500 51.0500
Subtotal (Total Children Is Unduplicated) 4 5.000000 255.2500 51.0500
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 6 13.000000 650.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 13 30.000000 2126.4100 70.8803
PHY-97110-PT SESSION BY LICENSED PT 20 65.000000 4586.8200 70.5665
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 37 144.500000 10272.2800 71.0884
Subtotal (Total Children Is Unduplicated) 59 252.500000 17635.5100 69.8436
-----------------------------------------------------------------------------------------------------------------------
Total 257.500000 17890.7600 69.4787
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 62
-----------------------------------------------------------------------------------------------------------------------
Center 05
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 119 251.000000 17533.6000 17533.6000
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
3 6.500000 357.1600 357.1600
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 122 257.500000 17890.7600 17890.7600