CMS/EIP Fiscal Report Center: 52
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-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 2.000000 111.0000 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 3 6.000000 333.0000 55.5000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 12 24.000000 1800.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 23 45.500000 3412.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 2 3.000000 225.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 3 6.000000 450.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 5 10.000000 555.0000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 25 50.000000 2775.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 2.000000 150.0000 75.0000
OCTH-97166TL-OT EVAL MODERATE COMPLEXITY 1 1.000000 51.0500 51.0500
OCTH-97166TLGT-OT EVAL MODERATE COMPLEXITY 1 1.000000 51.0500 51.0500
SCREEN-T1023-SCREENING 11 11.000000 550.0000 50.0000
SPCH-92523TL-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 5 5.000000 255.2500 51.0500
SPCH-92523TLGT-EVAL OF SPCH SOUND PROD; EVAL LANG COM 2 2.000000 102.1000 51.0500
SPCH-92610TLGT-EVAL OF ORAL,PHARYNGEAL SWALLOWING FUN 1 1.000000 44.5500 44.5500
Subtotal (Total Children Is Unduplicated) 80 173.500000 11165.5000 64.3545
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 75 196.500000 9825.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 88 297.250000 14862.5000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 1 2.000000 142.8800 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 1 2.000000 114.4000 57.2000
OCCT-97530TL-OT SESSION BY LICENSED OT 21 41.750000 2911.1800 69.7289
OCCT-97530TLGT-OT SESSION BY LICENSED OT 26 99.250000 7090.4200 71.4400
OCCT-97530TLGTHM-OT SESSION BY OT ASST 8 28.000000 1601.6000 57.2000
OCCT-97530TLHM-OT SESSION BY OT ASST 3 4.000000 228.8000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 1 2.000000 142.8800 71.4400
PHY-97110TL-PT SESSION BY LICENSED PT 25 61.500000 4393.5600 71.4400
PHY-97110TLGT-PT SESSION BY LICENSED PT 19 75.250000 5375.8600 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 3 3.000000 214.3200 71.4400
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 32 75.500000 5393.7200 71.4400
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 27 111.250000 7947.7000 71.4400
Subtotal (Total Children Is Unduplicated) 221 999.250000 60244.8200 60.2900
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Total 1172.750000 71410.3200 60.8913
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Number of Children (Unduplicated) With at Least One Service 263
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Center 52
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
628 1172.750000 71410.3200 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 628 1172.750000 71410.3200 0.0000