CMS/EIP Fiscal Report Center: 09
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
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 2 3.500000 262.5000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 6 12.000000 900.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 1 2.000000 111.0000 55.5000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 9 17.500000 1312.5000 75.0000
Subtotal (Total Children Is Unduplicated) 17 37.000000 2736.0000 73.9459
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EI Services,Class #03
OCCT-97530-OT SESSION BY LICENSED OT 16 101.000000 6368.4500 63.0540
OCCT-97530GT-OT SESSION BY LICENSED OT 1 1.000000 71.4400 71.4400
PHY-97110-PT SESSION BY LICENSED PT 25 160.000000 10416.8500 65.1053
PHY-97110GT-PT SESSION BY LICENSED PT 5 20.000000 1428.8000 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 57 384.500000 26058.9100 67.7735
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 15 92.000000 6326.2900 68.7640
Subtotal (Total Children Is Unduplicated) 95 758.500000 50670.7400 66.8039
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Total 795.500000 53406.7400 67.1361
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Number of Children (Unduplicated) With at Least One Service 109
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Center 09
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 68 168.000000 10091.6700 10091.6700
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 50 128.000000 7506.1900 7506.1900
146 481.500000 34458.8800 0.0000
Other 9 18.000000 1350.0000 0.0000
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Total 273 795.500000 53406.7400 17597.8600