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
Payclass Filters:OTHER
Eligibility Filter:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Screening, Eval, and Assessment,Class #02
OCTH-97167-OT EVAL HIGH COMPLEXITY 1 1.000000 51.0500 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 3 3.000000 153.1500 51.0500
Subtotal (Total Children Is Unduplicated) 3 4.000000 204.2000 51.0500
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EI Services,Class #03
CONOF-CONOF-CONSULT, OT, FACE TO FACE 4 4.000000 200.0000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 5 5.000000 250.0000 50.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 8 151.000000 3775.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 2 6.000000 300.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 17 32.000000 320.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 15 23.000000 1643.1200 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 29 89.500000 5119.4000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 3 11.000000 785.8400 71.4400
PHY-97110HM-PT SESSION BY PT ASST 12 43.500000 2486.4600 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 8 14.500000 1035.8800 71.4400
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 32 116.000000 6466.6000 55.7466
Subtotal (Total Children Is Unduplicated) 63 495.500000 22382.3000 45.1711
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Total 499.500000 22586.5000 45.2182
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Number of Children (Unduplicated) With at Least One Service 63
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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 1 1.000000 51.0500 51.0500
144 449.500000 21336.8500 21505.4500
Other 31 49.000000 1198.6000 1198.6000
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Total 176 499.500000 22586.5000 22755.1000