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
Payclass Filters:OTHER
Eligibility Filter:Program Patients
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 6 14.000000 1050.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 4 8.000000 600.0000 75.0000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 3 6.000000 333.0000 55.5000
SPCH-92523GT-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 1 1.000000 51.0500 51.0500
Subtotal (Total Children Is Unduplicated) 10 29.000000 2034.0500 70.1397
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 2 4.000000 200.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 2 6.500000 325.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 3 11.250000 803.7000 71.4400
OCCT-97530GT-OT SESSION BY LICENSED OT 1 7.500000 535.8000 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 1 2.000000 114.4000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 3 13.750000 982.3000 71.4400
PHY-97110GT-PT SESSION BY LICENSED PT 4 10.000000 714.4000 71.4400
PHY-97110HM-PT SESSION BY PT ASST 1 4.750000 271.5100 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 16 79.250000 5661.6200 71.4400
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 11 43.500000 3107.6400 71.4400
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 1 4.000000 285.7600 71.4400
Subtotal (Total Children Is Unduplicated) 28 186.500000 13002.1300 69.7165
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Total 215.500000 15036.1800 69.7735
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Number of Children (Unduplicated) With at Least One Service 34
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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 73 64.250000 4576.7500 4576.7500
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
163 151.250000 10459.4300 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 236 215.500000 15036.1800 4576.7500