CMS/EIP Fiscal Report Center: 57
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
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 2 4.000000 300.0000 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 1 2.000000 150.0000 75.0000
OCTH-97167-OT EVAL HIGH COMPLEXITY 16 16.000000 816.8000 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 5 6.000000 306.3000 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 11 11.000000 561.5500 51.0500
Subtotal (Total Children Is Unduplicated) 25 41.000000 2245.6500 54.7720
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 396 3203.000000 160150.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 15 67.250000 4804.3400 71.4400
PHY-97110-PT SESSION BY LICENSED PT 18 69.000000 4929.3600 71.4400
PHY-97110HM-PT SESSION BY PT ASST 3 38.000000 2172.0800 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 22 141.000000 10073.0400 71.4400
Subtotal (Total Children Is Unduplicated) 411 3518.250000 182128.8200 51.7669
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Total 3559.250000 184374.4700 51.8015
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Number of Children (Unduplicated) With at Least One Service 415
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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 161 87.500000 6230.6100 6230.6100
D 0 0.000000 0.0000 0.0000
S 35 20.500000 1403.3500 1403.3500
H 0 0.000000 0.0000 0.0000
T 907 3194.000000 160335.3600 160335.3600
196 257.250000 16405.1500 16405.1510
Other 0 0.000000 0.0000 0.0000
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Total 1299 3559.250000 184374.4700 184374.4710