CMS/EIP Fiscal Report Center: 53
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-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 4 6.000000 450.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 2 4.000000 222.0000 55.5000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 9 14.000000 1050.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 5 9.000000 675.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 45 83.500000 4634.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 14 21.000000 1575.0000 75.0000
Subtotal (Total Children Is Unduplicated) 70 137.500000 8606.2500 62.5909
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EI Services,Class #03
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 1 1.000000 25.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 188 853.500000 42675.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 13 51.250000 3661.3000 71.4400
PHY-97110-PT SESSION BY LICENSED PT 14 72.000000 5143.6800 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 12 44.000000 3143.3600 71.4400
Subtotal (Total Children Is Unduplicated) 227 1021.750000 54648.3400 53.4850
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Total 1159.250000 63254.5900 54.5651
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Number of Children (Unduplicated) With at Least One Service 280
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Center 53
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
1107 1159.250000 63254.5900 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 1107 1159.250000 63254.5900 0.0000