CMS/EIP Fiscal Report Center: 06
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
AUD-92593TS-AUDIOLOGY SERVICES (Biaural) 1 1.000000 50.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 6 36.000000 1800.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 2 4.000000 200.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 31 131.000000 8921.4500 68.1027
OCCT-97530GT-OT SESSION BY LICENSED OT 10 39.000000 2747.7800 70.4559
OCCT-97530HM-OT SESSION BY OT ASST 5 4.750000 271.7000 57.2000
OCCT-97530HMGT-OT SESSION BY OT ASST 5 7.750000 443.3000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 41 171.000000 11647.1400 68.1119
PHY-97110GT-PT SESSION BY LICENSED PT 18 34.000000 2334.2000 68.6529
PHY-97110HM-PT SESSION BY PT ASST 2 4.500000 257.2200 57.1600
PHY-97110HMGT-PT SESSION BY LICENSED PT ASST 1 0.500000 28.5800 57.1600
SENS-V5264-EARMOLD 1 2.000000 36.0000 18.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 109 405.000000 26848.2200 66.2919
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 48 155.000000 10891.4700 70.2675
SPL-92508-GROUP SPL SESSION PER CHILD 1 12.500000 138.8000 11.1040
Subtotal (Total Children Is Unduplicated) 217 1008.000000 66615.8600 66.0872
-----------------------------------------------------------------------------------------------------------------------
Total 1008.000000 66615.8600 66.0872
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 217
-----------------------------------------------------------------------------------------------------------------------
Center 06
Flag Claims Units Chgs Paid
---------------------------------------------------------
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 979 555.250000 36335.0800 36335.0800
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
791 452.750000 30280.7800 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1770 1008.000000 66615.8600 36335.0800