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: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
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 2 4.000000 300.0000 75.0000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 15 20.471734 1535.3801 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 26 40.069603 3005.2203 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 2 4.000000 300.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 2 3.500000 194.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 8 14.053867 1054.0400 75.0000
OCTF-97168-OT RE-EVAL EST PLAN CARE 6 6.000000 306.3000 51.0500
OCTH-97166-OT EVAL MODERATE COMPLEXITY 1 1.000000 51.0500 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 6 5.489716 280.2500 51.0500
PSTF-97164-PT RE-EVAL EST PLAN CARE 3 3.000000 153.1500 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 2 2.000000 102.1000 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 7 5.825465 297.3900 51.0500
Subtotal (Total Children Is Unduplicated) 63 109.410385 7579.1304 69.2725
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EI Services,Class #03
CONIP-CONIP-CONSULT, ITDS PHONE 2 2.000000 50.0000 25.0000
CONSP-CONSP-CONSULT, SLP, PHONE 3 2.500000 62.5000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 10 32.900000 1645.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 34 186.182400 13300.8700 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 42 195.011886 11154.6800 57.2000
PHY-97110-PT SESSION BY LICENSED PT 23 149.036953 10647.2000 71.4400
PHY-97110HM-PT SESSION BY PT ASST 18 101.668298 5811.3600 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 88 550.855391 39353.1100 71.4400
Subtotal (Total Children Is Unduplicated) 162 1220.154928 82024.7200 67.2248
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Total 1329.565313 89603.8504 67.3933
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Number of Children (Unduplicated) With at Least One Service 192
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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 714 682.854117 46214.7800 46214.7800
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
794 646.711196 43389.0704 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 1508 1329.565313 89603.8504 46214.7800