CMS/EIP Fiscal Report Center: 05
Services beginning 01/01/2020 ending 03/31/2020 Date of Report:05/15/2020 Page: 1
List order: No List
Payclass Filters:TPIN
Eligibility Filter:Program Patients
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 1 1.000000 36.6900 36.6900
OCTH-97167-OT EVAL HIGH COMPLEXITY 3 3.000000 153.1500 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 3 3.000000 153.1500 51.0500
SPCH-92521-EVAL OF SPEECH FLUENCY 1 1.000000 51.0500 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 6 8.000000 388.9000 48.6125
SPCH-92610-EVAL OF ORAL,PHARYNGEAL SWALLOWING FUNC 2 2.000000 89.1000 44.5500
Subtotal (Total Children Is Unduplicated) 16 18.000000 872.0400 48.4467
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 18 39.250000 1962.5000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 28 83.250000 5496.0100 66.0181
OCCT-97530GT-OT SESSION BY LICENSED OT 1 4.000000 285.7600 71.4400
PHY-97110-PT SESSION BY LICENSED PT 25 94.000000 5764.5600 61.3251
PHY-97110HM-PT SESSION BY PT ASST 1 1.000000 14.3700 14.3700
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 68 224.750000 14681.4300 65.3234
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 2 2.000000 113.1000 56.5500
Subtotal (Total Children Is Unduplicated) 115 448.250000 28317.7300 63.1740
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Total 466.250000 29189.7700 62.6054
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Number of Children (Unduplicated) With at Least One Service 121
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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 265 451.250000 28147.9500 28147.9500
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
9 15.000000 1041.8200 1041.8200
Other 0 0.000000 0.0000 0.0000
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Total 274 466.250000 29189.7700 29189.7700