CMS/EIP Fiscal Report Center: 57
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
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 1 2.000000 111.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 2 4.000000 300.0000 75.0000
OCTH-97167-OT EVAL HIGH COMPLEXITY 14 16.000000 816.8000 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 17 17.000000 867.8500 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 24 25.000000 1276.2500 51.0500
Subtotal (Total Children Is Unduplicated) 40 66.000000 3521.9000 53.3621
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 839 6426.000000 321300.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 29 181.750000 12984.2200 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 22 96.750000 5534.1000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 17 79.000000 5643.7600 71.4400
PHY-97110HM-PT SESSION BY PT ASST 24 121.750000 6959.2300 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 27 87.000000 6215.2800 71.4400
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 24 124.750000 7135.7000 57.2000
Subtotal (Total Children Is Unduplicated) 886 7117.000000 365772.2900 51.3942
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Total 7183.000000 369294.1900 51.4122
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Number of Children (Unduplicated) With at Least One Service 891
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Center 57
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
2128 7183.000000 369294.1900 369294.1900
Other 0 0.000000 0.0000 0.0000
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Total 2128 7183.000000 369294.1900 369294.1900