CMS/EIP Fiscal Report Center: 51
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: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-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 1 1.000000 75.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 16 16.000000 1200.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 7 7.000000 525.0000 75.0000
SPCH-92521GT-EVAL OF SPEECH FLUENCY 1 1.000000 51.0500 51.0500
Subtotal (Total Children Is Unduplicated) 25 25.000000 1851.0500 74.0420
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 16 36.500000 1825.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 22 69.500000 3475.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 11 40.000000 2857.6000 71.4400
OCCT-97530GT-OT SESSION BY LICENSED OT 1 1.000000 71.4400 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 1 1.000000 57.2000 57.2000
OCCT-97530HMGT-OT SESSION BY OT ASST 2 9.000000 514.8000 57.2000
OCCT-97530TLGT-OT SESSION BY LICENSED OT 1 1.000000 71.4400 71.4400
PHY-97110-PT SESSION BY LICENSED PT 2 6.750000 482.2200 71.4400
PHY-97110GT-PT SESSION BY LICENSED PT 4 15.000000 779.1500 51.9433
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 19 60.500000 4322.1200 71.4400
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 36 96.500000 6893.9600 71.4400
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 1 4.000000 285.7600 71.4400
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 3 10.000000 714.4000 71.4400
SPL-92508TLGT-SPL THERAPY SESSION BY LICENSED SLP 1 1.000000 13.8800 13.8800
Subtotal (Total Children Is Unduplicated) 99 351.750000 22363.9700 63.5792
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Total 376.750000 24215.0200 64.2734
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Number of Children (Unduplicated) With at Least One Service 123
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Center 51
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
150 376.750000 24215.0200 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 150 376.750000 24215.0200 0.0000