CMS/EIP Fiscal Report Center: 04
Services beginning 10/01/2019 ending 12/31/2019 Date of Report:02/01/2020 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
OCTH-97166-OT EVAL MODERATE COMPLEXITY 4 4.000000 204.2000 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 14 14.000000 714.7000 51.0500
PSTH-97162-PT EVAL MODERATE COMPLEXITY 1 1.000000 51.0500 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 4 4.000000 204.2000 51.0500
SPCH-92524-BEHAV & QUAL ANALYSIS OF VOICE AND RES 1 1.000000 51.0500 51.0500
Subtotal (Total Children Is Unduplicated) 24 27.000000 1378.3500 51.0500
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 7 94.000000 4700.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 22 65.000000 4643.6000 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 14 72.000000 4118.4000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 15 75.750000 5277.1200 69.6650
PHY-97110HM-PT SESSION BY PT ASST 1 4.000000 228.6400 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 18 70.000000 4800.8000 68.5829
SPL-92508-GROUP SPL SESSION PER CHILD 1 1.000000 13.8800 13.8800
Subtotal (Total Children Is Unduplicated) 50 381.750000 23782.4400 62.2985
-----------------------------------------------------------------------------------------------------------------------
Total 408.750000 25160.7900 61.5554
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 54
-----------------------------------------------------------------------------------------------------------------------
Center 04
Flag Claims Units Chgs Paid
---------------------------------------------------------
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 94 215.250000 13906.2600 9540.4600
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 27 109.000000 5623.0500 0.0000
T 0 0.000000 0.0000 0.0000
0 0.000000 0.0000 0.0000
Other 41 84.500000 5631.4800 0.0000
---------------------------------------------------------
Total 162 408.750000 25160.7900 9540.4600