CMS/EIP Fiscal Report Center: 05
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
OCTH-97167-OT EVAL HIGH COMPLEXITY 1 1.000000 51.0500 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 1 1.000000 51.0500 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 5 5.000000 222.0600 44.4120
SPCH-92523GT-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 2 2.000000 102.1000 51.0500
Subtotal (Total Children Is Unduplicated) 9 11.000000 576.2600 52.3873
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EI Services,Class #03
OCCT-97530-OT SESSION BY LICENSED OT 8 35.750000 2449.9100 68.5290
PHY-97110-PT SESSION BY LICENSED PT 18 107.500000 6745.8200 62.7518
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 27 84.500000 4885.5700 57.8174
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 6 14.500000 1035.8800 71.4400
Subtotal (Total Children Is Unduplicated) 46 242.250000 15117.1800 62.4032
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Total 253.250000 15693.4400 61.9682
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Number of Children (Unduplicated) With at Least One Service 53
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Center 05
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 127 233.250000 14384.0900 14384.0900
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
10 20.000000 1309.3500 1309.3500
Other 0 0.000000 0.0000 0.0000
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Total 137 253.250000 15693.4400 15693.4400