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: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
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 1 2.000000 150.0000 75.0000
OCTH-97167-OT EVAL HIGH COMPLEXITY 6 6.000000 306.3000 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 3 3.000000 153.1500 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 12 12.000000 612.6000 51.0500
Subtotal (Total Children Is Unduplicated) 18 25.000000 1333.0500 53.3220
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 383 3240.000000 162000.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 14 83.250000 5947.3800 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 10 26.000000 1487.2000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 15 90.750000 6483.1800 71.4400
PHY-97110HM-PT SESSION BY PT ASST 8 26.000000 1486.1600 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 19 124.250000 8876.4200 71.4400
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 8 17.500000 1001.0000 57.2000
Subtotal (Total Children Is Unduplicated) 409 3607.750000 187281.3400 51.9108
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Total 3632.750000 188614.3900 51.9206
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Number of Children (Unduplicated) With at Least One Service 409
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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 117 60.000000 4225.2300 4225.2300
D 0 0.000000 0.0000 0.0000
S 9 4.500000 321.4800 321.4800
H 0 0.000000 0.0000 0.0000
T 934 3230.000000 161945.5900 161945.5900
215 338.250000 22122.0900 22321.0800
Other 0 0.000000 0.0000 0.0000
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Total 1275 3632.750000 188614.3900 188813.3800