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
Payclass Filters:OTHER
Eligibility Filter:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
EI Services,Class #03
CONOF-CONOF-CONSULT, OT, FACE TO FACE 2 2.000000 100.0000 50.0000
CONSF-CONSFGT-CONSULT,SLP,FACE TO FACE 1 0.500000 25.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 3 4.000000 285.7600 71.4400
PHY-97110-PT SESSION BY LICENSED PT 1 0.750000 53.5800 71.4400
PHY-97110TL-PT SESSION BY LICENSED PT 1 0.750000 53.5800 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 2 2.000000 142.8800 71.4400
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 1 2.000000 142.8800 71.4400
Subtotal (Total Children Is Unduplicated) 11 12.000000 803.6800 66.9733
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Total 12.000000 803.6800 66.9733
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Number of Children (Unduplicated) With at Least One Service 11
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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 1 0.500000 25.0000 25.0000
11 11.500000 778.6800 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 12 12.000000 803.6800 25.0000