CMS/EIP Fiscal Report Center: 52
Services beginning 07/01/2019 ending 09/30/2019 Date of Report:11/04/2019 Page: 1
List order: No List
Agency Filter:EXT
Payclass Filters:MED
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
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 5 10.000000 555.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 4 8.000000 600.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 6 11.000000 825.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 51 100.000000 5550.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 7 14.000000 1050.0000 75.0000
OCTH-97166-OT EVAL MODERATE COMPLEXITY 2 2.000000 102.1000 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 2 2.000000 102.1000 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 1 1.000000 51.0500 51.0500
SCREEN-T1023-SCREENING 4 4.000000 200.0000 50.0000
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 6 6.000000 306.3000 51.0500
Subtotal (Total Children Is Unduplicated) 81 160.000000 9491.5500 59.3222
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 147 801.750000 40087.5000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 49 211.500000 15109.5600 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 31 154.000000 8808.8000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 41 209.750000 14944.5400 71.2493
PHY-97110HM-PT SESSION BY PT ASST 4 17.000000 971.7200 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 77 414.000000 29576.1600 71.4400
SPL-92508-GROUP SPL SESSION PER CHILD 2 3.750000 52.0500 13.8800
Subtotal (Total Children Is Unduplicated) 296 1811.750000 109550.3300 60.4666
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Total 1971.750000 119041.8800 60.3737
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Number of Children (Unduplicated) With at Least One Service 336
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Center 52
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 0 0.000000 0.0000 0.0000
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
926 1971.750000 119041.8800 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 926 1971.750000 119041.8800 0.0000