CMS/EIP Fiscal Report Center: 03
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
EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1 2.000000 100.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 7 18.500000 1210.2200 65.4173
OCCT-97530GT-OT SESSION BY LICENSED OT 1 1.000000 71.4400 71.4400
PHY-97110-PT SESSION BY LICENSED PT 1 2.000000 142.8800 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 4 8.000000 374.1000 46.7625
Subtotal (Total Children Is Unduplicated) 14 31.500000 1898.6400 60.2743
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Total 31.500000 1898.6400 60.2743
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Number of Children (Unduplicated) With at Least One Service 14
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Center 03
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 30 29.500000 1755.7600 1755.7600
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
2 2.000000 142.8800 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 32 31.500000 1898.6400 1755.7600