CMS/EIP Fiscal Report Center: 55
Services beginning 01/01/2020 ending 03/31/2020 Date of Report:05/15/2020 Page: 1
List order: No List
Agency Filter:EXT
Payclass Filters:MED
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
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 3 6.000000 450.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 3 6.000000 450.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 2.000000 111.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 25 50.000000 3750.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 71 142.000000 10650.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 23 46.000000 3450.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 27 54.000000 2997.0000 55.5000
OCTF-97168-OT RE-EVAL EST PLAN CARE 6 6.000000 306.3000 51.0500
OCTH-97166-OT EVAL MODERATE COMPLEXITY 1 1.000000 51.0500 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 22 22.000000 1123.1000 51.0500
PSTF-97164-PT RE-EVAL EST PLAN CARE 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 12 13.000000 663.6500 51.0500
SPCH-92610-EVAL OF ORAL,PHARYNGEAL SWALLOWING FUNC 1 1.000000 48.9400 48.9400
Subtotal (Total Children Is Unduplicated) 157 353.000000 24255.2400 68.7117
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EI Services,Class #03
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 4 12.750000 318.7500 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 333 2397.500000 119875.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 8 9.000000 450.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 78 512.500000 36613.0000 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 103 603.000000 34491.6000 57.2000
OCCT-97530HMGT-OT SESSION BY OT ASST 3 5.000000 286.0000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 29 202.750000 14484.4600 71.4400
PHY-97110GT-PT SESSION BY LICENSED PT 1 1.000000 71.4400 71.4400
PHY-97110HM-PT SESSION BY PT ASST 34 205.000000 11717.8000 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 138 795.660134 56841.9600 71.4400
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 3 3.000000 214.3200 71.4400
SPL-92508-GROUP SPL SESSION PER CHILD 1 3.000000 41.6400 13.8800
Subtotal (Total Children Is Unduplicated) 564 4750.160134 275405.9700 57.9783
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Total 5103.160134 299661.2100 58.7207
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Number of Children (Unduplicated) With at Least One Service 616
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Center 55
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 0 0.000000 0.0000 0.0000
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
5030 5103.160134 299661.2100 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 5030 5103.160134 299661.2100 0.0000