CMS/EIP Fiscal Report Center: 05
Services beginning 04/01/2020 ending 06/30/2020 Date of Report:07/21/2020 Page: 1
List order: No List
Agency Filter:EXT
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
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 1 2.000000 150.0000 75.0000
PSTF-97164-PT RE-EVAL EST PLAN CARE 1 1.000000 51.0500 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 1 1.000000 51.0500 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 2 2.000000 102.1000 51.0500
SPCH-92523GT-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 1 1.000000 51.0500 51.0500
Subtotal (Total Children Is Unduplicated) 6 7.000000 405.2500 57.8929
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 4 11.000000 550.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 5 15.000000 750.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 3 7.500000 535.8000 71.4400
OCCT-97530GT-OT SESSION BY LICENSED OT 5 15.250000 858.2400 56.2780
PHY-97110-PT SESSION BY LICENSED PT 12 49.750000 2832.0100 56.9248
PHY-97110GT-PT SESSION BY LICENSED PT 11 45.000000 2241.5500 49.8122
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 11 26.000000 1732.2000 66.6231
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 22 68.250000 4024.0500 58.9604
Subtotal (Total Children Is Unduplicated) 55 237.750000 13523.8500 56.8827
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Total 244.750000 13929.1000 56.9115
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Number of Children (Unduplicated) With at Least One Service 58
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Center 05
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 104 200.500000 11152.3300 11152.3300
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
21 44.250000 2776.7700 2776.7700
Other 0 0.000000 0.0000 0.0000
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Total 125 244.750000 13929.1000 13929.1000