CMS/EIP Fiscal Report Center: 05
Services beginning 10/01/2019 ending 12/31/2019 Date of Report:02/01/2020 Page: 1
List order: No List
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-97167-OT EVAL HIGH COMPLEXITY 2 2.000000 102.1000 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 2 2.000000 102.1000 51.0500
Subtotal (Total Children Is Unduplicated) 6 7.000000 357.3500 51.0500
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 8 31.000000 1550.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 7 18.750000 1339.5000 71.4400
PHY-97110-PT SESSION BY LICENSED PT 14 44.750000 3196.9400 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 31 126.000000 9001.4400 71.4400
Subtotal (Total Children Is Unduplicated) 50 220.500000 15087.8800 68.4258
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Total 227.500000 15445.2300 67.8911
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Number of Children (Unduplicated) With at Least One Service 52
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Center 05
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 117 198.500000 13501.0600 13501.0600
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
16 29.000000 1944.1700 1944.1700
Other 0 0.000000 0.0000 0.0000
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Total 133 227.500000 15445.2300 15445.2300