CMS/EIP Fiscal Report Center: 02
Services beginning 04/01/2020 ending 06/30/2020 Date of Report:07/21/2020 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
OCTF-97168-OT RE-EVAL EST PLAN CARE 1 1.000000 51.0500 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 1 1.000000 22.8300 22.8300
SPCH-92522GT-EVAL OF SPCH SOUND PROD 1 1.000000 51.0500 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 4 4.000000 184.2000 46.0500
SPCH-92523GT-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 3 3.000000 153.1500 51.0500
Subtotal (Total Children Is Unduplicated) 9 10.000000 462.2800 46.2280
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 1 1.000000 1717.6000 1717.6000
OCCT-97530-OT SESSION BY LICENSED OT 3 9.250000 563.6600 60.9362
OCCT-97530GT-OT SESSION BY LICENSED OT 4 27.000000 1550.8100 57.4374
PHY-97110-PT SESSION BY LICENSED PT 6 9.250000 499.3600 53.9849
PHY-97110GT-PT SESSION BY LICENSED PT 6 19.750000 1227.7100 62.1625
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 21 135.000000 9620.2500 71.2611
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 12 68.000000 4757.9200 69.9694
Subtotal (Total Children Is Unduplicated) 41 269.250000 19937.3100 74.0476
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Total 279.250000 20399.5900 73.0514
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Number of Children (Unduplicated) With at Least One Service 42
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Center 02
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 152 136.500000 9060.0600 9060.0600
171 142.750000 11339.5300 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 323 279.250000 20399.5900 9060.0600