CMS/EIP Fiscal Report Center: 53
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-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 1 2.000000 111.0000 55.5000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 4 7.500000 562.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 1 2.000000 111.0000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 3 5.000000 277.5000 55.5000
Subtotal (Total Children Is Unduplicated) 9 18.500000 1212.0000 65.5135
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 3 10.000000 500.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 25 88.000000 4400.0000 50.0000
OCCT-97530GT-OT SESSION BY LICENSED OT 4 8.500000 607.2400 71.4400
PHY-97110GT-PT SESSION BY LICENSED PT 5 15.000000 1071.6000 71.4400
Subtotal (Total Children Is Unduplicated) 37 121.500000 6578.8400 54.1468
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Total 140.000000 7790.8400 55.6489
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Number of Children (Unduplicated) With at Least One Service 43
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Center 53
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 16 16.000000 800.0000 800.0000
117 124.000000 6990.8400 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 133 140.000000 7790.8400 800.0000