CMS/EIP Fiscal Report Center: 04
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:Part C (excluding not eligible)
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Screening, Eval, and Assessment,Class #02
EVAL-96111-DEVELOPMENTAL EVALUATION 1 0.750000 37.5000 50.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 6 8.500000 637.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 1 1.000000 75.0000 75.0000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 2 3.500000 194.2500 55.5000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 20 26.500000 1987.5000 75.0000
OCTF-97168-OT RE-EVAL EST PLAN CARE 1 1.000000 51.0500 51.0500
OCTH-97166-OT EVAL MODERATE COMPLEXITY 1 1.000000 51.0500 51.0500
OCTH-97167GT-OT EVAL HIGH COMPLEXITY 1 1.000000 14.7300 14.7300
PSTF-97164-PT RE-EVAL EST PLAN CARE 1 1.000000 51.0500 51.0500
PSTH-97162GT-PT EVAL MODERATE COMPLEXITY 1 1.000000 27.4900 27.4900
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 220.1600 44.0320
Subtotal (Total Children Is Unduplicated) 37 52.250000 3449.3800 66.0168
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 3 15.000000 750.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 3 19.000000 950.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 13 42.750000 2866.3400 67.0489
OCCT-97530GT-OT SESSION BY LICENSED OT 3 31.000000 1854.5600 59.8245
OCCT-97530HM-OT SESSION BY OT ASST 2 11.000000 434.0000 39.4545
PHY-97110-PT SESSION BY LICENSED PT 18 84.500000 5790.2000 68.5231
PHY-97110GT-PT SESSION BY LICENSED PT 3 19.000000 1196.7200 62.9853
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 14 61.500000 4085.4500 66.4301
Subtotal (Total Children Is Unduplicated) 48 283.750000 17927.2700 63.1798
-----------------------------------------------------------------------------------------------------------------------
Total 336.000000 21376.6500 63.6210
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 74
-----------------------------------------------------------------------------------------------------------------------
Center 04
Flag Claims Units Chgs Paid
---------------------------------------------------------
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 66 161.750000 9781.8900 4036.0300
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 12 35.000000 1771.4400 0.0000
T 0 0.000000 0.0000 0.0000
33 40.250000 2931.7500 0.0000
Other 39 99.000000 6891.5700 908.3300
---------------------------------------------------------
Total 150 336.000000 21376.6500 4944.3600