CMS/EIP Fiscal Report Center: 51
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-97165-OT EVAL LOW COMPLEXITY 1 1.000000 51.0500 51.0500
OCTH-97166-OT EVAL MODERATE COMPLEXITY 1 1.000000 51.0500 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 4 4.000000 172.5300 43.1325
PSTH-97163-PT EVAL HIGH COMPLEXITY 2 2.000000 102.1000 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 5 5.000000 255.2500 51.0500
Subtotal (Total Children Is Unduplicated) 13 13.000000 631.9800 48.6138
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 3 6.000000 300.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 40 167.000000 11454.4100 68.5893
OCCT-97530HM-OT SESSION BY OT ASST 27 110.750000 6334.9000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 21 64.250000 4590.0200 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 70 293.000000 20873.0200 71.2390
Subtotal (Total Children Is Unduplicated) 106 641.000000 43552.3500 67.9444
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Total 654.000000 44184.3300 67.5601
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Number of Children (Unduplicated) With at Least One Service 113
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Center 51
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 211 604.500000 40668.4400 40668.4400
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 49.500000 3515.8900 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 227 654.000000 44184.3300 40668.4400