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:TPIN
Eligibility Filter:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Screening, Eval, and Assessment,Class #02
EVAL-96111-DEVELOPMENTAL EVALUATION 2 3.000000 150.0000 50.0000
EXIT-EXIT-EXIT ASSESSMENT 10 12.000000 600.0000 50.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 3 4.829867 362.2400 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 45 85.159734 6386.9800 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 9 13.044666 978.3500 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 19 42.000000 3150.0000 75.0000
OCTF-97168-OT RE-EVAL EST PLAN CARE 2 1.859941 94.9500 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 5 5.000000 255.2500 51.0500
PSTF-97164-PT RE-EVAL EST PLAN CARE 1 1.000000 51.0500 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 2 2.000000 102.1000 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 14 12.175319 621.5500 51.0500
SPCH-92523GT-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 3 3.000000 153.1500 51.0500
SPCH-92610-EVAL OF ORAL,PHARYNGEAL SWALLOWING FUNC 1 1.000000 48.9400 48.9400
Subtotal (Total Children Is Unduplicated) 91 192.069527 13404.5600 69.7901
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 1 1.000000 523.8000 523.8000
CONOF-CONOFGT-CONSULT,OT,FACE TO FACE 2 4.000000 200.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 9 41.000000 2050.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 3 17.000000 850.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 1 3.000000 30.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 16 74.888439 5350.0300 71.4400
OCCT-97530GT-OT SESSION BY LICENSED OT 8 36.814110 2630.0000 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 21 94.757168 5420.1100 57.2000
OCCT-97530HMGT-OT SESSION BY OT ASST 25 103.840210 5939.6600 57.2000
PHY-97110-PT SESSION BY LICENSED PT 6 13.750000 982.3000 71.4400
PHY-97110GT-PT SESSION BY LICENSED PT 5 17.500000 1250.2000 71.4400
PHY-97110HM-PT SESSION BY PT ASST 8 66.500000 3801.1400 57.1600
PHY-97110HMGT-PT SESSION BY LICENSED PT ASST 6 20.677923 1181.9500 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 53 294.758958 21057.5797 71.4400
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 29 128.958707 9212.8100 71.4400
Subtotal (Total Children Is Unduplicated) 114 918.445515 60479.5797 65.8499
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Total 1110.515042 73884.1397 66.5314
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Number of Children (Unduplicated) With at Least One Service 180
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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 433 385.500000 25704.5500 25704.5500
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 50 80.000000 5637.9400 0.0000
T 0 0.000000 0.0000 0.0000
712 645.015042 42541.6497 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 1195 1110.515042 73884.1397 25704.5500