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:OTHER
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
Subtotal (Total Children Is Unduplicated) 2 6.000000 411.0000 68.5000
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EI Services,Class #03
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 1 3.750000 93.7500 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 7 44.000000 2200.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 3 11.000000 785.8400 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 5 16.000000 915.2000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 4 21.000000 1500.2400 71.4400
PHY-97110GT-PT SESSION BY LICENSED PT 1 2.000000 142.8800 71.4400
PHY-97110HM-PT SESSION BY PT ASST 2 5.000000 285.8000 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 10 41.000000 2929.0400 71.4400
Subtotal (Total Children Is Unduplicated) 24 143.750000 8852.7500 61.5843
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Total 149.750000 9263.7500 61.8614
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Number of Children (Unduplicated) With at Least One Service 25
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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 59 62.000000 4211.7600 4211.7600
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
89 87.750000 5051.9900 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 148 149.750000 9263.7500 4211.7600