CMS/EIP Fiscal Report Center: 55
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-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 2 4.000000 300.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 5 10.000000 750.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 2.000000 150.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 2.000000 111.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 23 46.000000 3450.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 74 148.000000 11100.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 7 14.000000 1050.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 23 46.000000 2553.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 29 57.946133 4345.9600 75.0000
OCTF-97168-OT RE-EVAL EST PLAN CARE 13 13.000000 663.6500 51.0500
OCTH-97166-OT EVAL MODERATE COMPLEXITY 3 3.000000 153.1500 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 5 5.000000 255.2500 51.0500
PSTF-97164-PT RE-EVAL EST PLAN CARE 2 2.000000 102.1000 51.0500
PSTH-97162-PT EVAL MODERATE COMPLEXITY 1 1.000000 51.0500 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 1 1.000000 51.0500 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 16 16.000000 816.8000 51.0500
Subtotal (Total Children Is Unduplicated) 158 370.946133 25903.0100 69.8296
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EI Services,Class #03
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 4 13.250000 331.2500 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 258 1437.250000 71862.5000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 78 363.500000 25968.4400 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 97 472.000000 26998.4000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 49 206.440090 14748.0800 71.4400
PHY-97110HM-PT SESSION BY PT ASST 32 133.900105 7653.7300 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 140 801.753920 57277.3000 71.4400
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 1 2.000000 114.4000 57.2000
Subtotal (Total Children Is Unduplicated) 511 3430.094115 204954.1000 59.7517
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Total 3801.040248 230857.1100 60.7352
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Number of Children (Unduplicated) With at Least One Service 576
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Center 55
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 1 2.000000 150.0000 150.0000
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
3709 3799.040248 230707.1100 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 3710 3801.040248 230857.1100 150.0000