CMS/EIP Fiscal Report Center: 55
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-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 1 2.000000 150.0000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 1 2.000000 111.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 2 4.000000 300.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 7 14.000000 1050.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 12 24.000000 1800.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 36 72.000000 5400.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 2 4.000000 222.0000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 6 12.000000 666.0000 55.5000
OCTF-97168-OT RE-EVAL EST PLAN CARE 1 1.000000 51.0500 51.0500
OCTF-97168GT-OT RE-EVAL EST PLAN CARE 2 2.000000 102.1000 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 5 5.000000 255.2500 51.0500
OCTH-97167GT-OT EVAL HIGH COMPLEXITY 3 3.000000 153.1500 51.0500
OCTH-97167TLGT-OT EVAL HIGH COMPLEXITY 1 1.000000 51.0500 51.0500
PSTF-97164-PT RE-EVAL EST PLAN CARE 1 1.000000 51.0500 51.0500
PSTH-97163GT-PT EVAL HIGH COMPLEXITY 2 2.000000 102.1000 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 5 5.000000 255.2500 51.0500
SPCH-92523GT-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 2 2.000000 102.1000 51.0500
SPCH-92610-EVAL OF ORAL,PHARYNGEAL SWALLOWING FUNC 1 1.000000 48.9400 48.9400
Subtotal (Total Children Is Unduplicated) 83 161.000000 11171.0400 69.3853
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 133 702.000000 35100.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 100 372.750000 18637.5000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 34 187.250000 13377.1400 71.4400
OCCT-97530GT-OT SESSION BY LICENSED OT 16 81.000000 5786.6400 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 36 88.250000 5047.9000 57.2000
OCCT-97530HMGT-OT SESSION BY OT ASST 16 82.500000 4719.0000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 18 82.000000 5858.0800 71.4400
PHY-97110GT-PT SESSION BY LICENSED PT 4 11.250000 803.7000 71.4400
PHY-97110HM-PT SESSION BY PT ASST 19 104.000000 5944.6400 57.1600
PHY-97110HMGT-PT SESSION BY LICENSED PT ASST 4 17.500000 1000.3000 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 83 481.000000 34362.6400 71.4400
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 21 72.750000 5197.2600 71.4400
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 1 8.000000 571.5200 71.4400
Subtotal (Total Children Is Unduplicated) 356 2290.250000 136406.3200 59.5596
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Total 2451.250000 147577.3600 60.2049
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Number of Children (Unduplicated) With at Least One Service 411
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Center 55
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 1 2.000000 150.0000 150.0000
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
2469 2449.250000 147427.3600 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 2470 2451.250000 147577.3600 150.0000