CMS/EIP Fiscal Report Center: 52
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:MED
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-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 3 6.000000 450.0000 75.0000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 2 4.000000 222.0000 55.5000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 48 95.000000 7125.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 5 10.000000 750.0000 75.0000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 23 46.000000 2553.0000 55.5000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 3 6.000000 450.0000 75.0000
OCTH-97166TL-OT EVAL MODERATE COMPLEXITY 7 7.000000 357.3500 51.0500
OCTH-97166TLGT-OT EVAL MODERATE COMPLEXITY 1 1.000000 51.0500 51.0500
PSTH-97162TL-PT EVAL MODERATE COMPLEXITY 1 1.000000 51.0500 51.0500
SCREEN-T1023-SCREENING 11 11.000000 550.0000 50.0000
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 1 1.000000 51.0500 51.0500
SPCH-92523TL-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 8 8.000000 408.4000 51.0500
SPCH-92523TLGT-EVAL OF SPCH SOUND PROD; EVAL LANG COM 1 1.000000 51.0500 51.0500
Subtotal (Total Children Is Unduplicated) 101 199.000000 13219.9500 66.4319
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 97 568.500000 28425.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 28 74.250000 3712.5000 50.0000
OCCT-97530GT-OT SESSION BY LICENSED OT 1 1.000000 71.4400 71.4400
OCCT-97530TL-OT SESSION BY LICENSED OT 36 194.750000 13912.9400 71.4400
OCCT-97530TLGT-OT SESSION BY LICENSED OT 14 27.500000 1964.6000 71.4400
OCCT-97530TLGTHM-OT SESSION BY OT ASST 3 4.500000 257.4000 57.2000
OCCT-97530TLHM-OT SESSION BY OT ASST 7 14.500000 829.4000 57.2000
PHY-97110TL-PT SESSION BY LICENSED PT 30 168.500000 12037.6400 71.4400
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 65 304.750000 21771.3400 71.4400
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 2 11.250000 803.7000 71.4400
Subtotal (Total Children Is Unduplicated) 224 1369.500000 83785.9600 61.1800
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Total 1568.500000 97005.9100 61.8463
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Number of Children (Unduplicated) With at Least One Service 285
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Center 52
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 0 0.000000 0.0000 0.0000
727 1568.500000 97005.9100 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 727 1568.500000 97005.9100 0.0000