CMS/EIP Fiscal Report Center: 02
Services beginning 10/01/2020 ending 12/31/2020 Date of Report:01/23/2021 Page: 1
List order: No List
Agency Filter:EXT
Payclass Filters:TPIN
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
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 1 2.000000 150.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 2 3.500000 262.5000 75.0000
OCTH-97165GT-OT EVAL LOW COMPLEXITY 1 1.000000 51.0500 51.0500
PSTF-97164GT-PT RE-EVAL EST PLAN CARE 1 1.000000 51.0500 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 4 4.000000 184.2000 46.0500
SPCH-92523GT-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 4 4.000000 204.2000 51.0500
Subtotal (Total Children Is Unduplicated) 12 15.500000 903.0000 58.2581
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EI Services,Class #03
OCCT-97530-OT SESSION BY LICENSED OT 3 13.000000 928.7200 71.4400
OCCT-97530GT-OT SESSION BY LICENSED OT 4 20.000000 1428.8000 71.4400
PHY-97110-PT SESSION BY LICENSED PT 10 48.000000 3049.5700 63.5327
PHY-97110GT-PT SESSION BY LICENSED PT 2 6.000000 272.7800 45.4633
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 26 112.000000 7793.5200 69.5850
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 12 55.000000 3929.2000 71.4400
Subtotal (Total Children Is Unduplicated) 45 254.000000 17402.5900 68.5141
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Total 269.500000 18305.5900 67.9243
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Number of Children (Unduplicated) With at Least One Service 48
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Center 02
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 274 236.750000 16270.4900 16270.4900
53 32.750000 2035.1000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 327 269.500000 18305.5900 16270.4900