CMS/EIP Fiscal Report Center: 55
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-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 1 2.000000 111.0000 55.5000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 11 22.000000 1650.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 4 8.000000 600.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 45 90.000000 6750.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 18 36.000000 2700.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 4 8.000000 444.0000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 32 63.000000 3496.5000 55.5000
OCTF-97168-OT RE-EVAL EST PLAN CARE 5 5.000000 255.2500 51.0500
OCTF-97168GT-OT RE-EVAL EST PLAN CARE 4 4.000000 204.2000 51.0500
OCTH-97166-OT EVAL MODERATE COMPLEXITY 1 1.000000 51.0500 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 14 14.000000 714.7000 51.0500
OCTH-97167GT-OT EVAL HIGH COMPLEXITY 2 2.000000 102.1000 51.0500
OCTH-97167TL-OT EVAL HIGH COMPLEXITY 1 1.000000 51.0500 51.0500
PSTF-97164GT-PT RE-EVAL EST PLAN CARE 1 1.000000 51.0500 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 3 3.000000 153.1500 51.0500
PSTH-97163GT-PT EVAL HIGH COMPLEXITY 1 1.000000 51.0500 51.0500
PSTH-97163TL-PT EVAL HIGH COMPLEXITY 1 1.000000 51.0500 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 7 7.000000 357.3500 51.0500
Subtotal (Total Children Is Unduplicated) 132 269.000000 17793.5000 66.1468
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 1 2.000000 158.1200 79.0600
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 1 5.000000 125.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 177 1053.500000 52675.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 39 139.750000 6987.5000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 67 360.000000 25718.4000 71.4400
OCCT-97530GT-OT SESSION BY LICENSED OT 3 7.000000 500.0800 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 70 520.000000 29744.0000 57.2000
OCCT-97530HMGT-OT SESSION BY OT ASST 7 40.000000 2288.0000 57.2000
OCCT-97530TL-OT SESSION BY LICENSED OT 13 51.000000 3643.4400 71.4400
OCCT-97530TLGT-OT SESSION BY LICENSED OT 1 7.000000 500.0800 71.4400
OCCT-97530TLGTHM-OT SESSION BY OT ASST 2 11.000000 629.2000 57.2000
OCCT-97530TLHM-OT SESSION BY OT ASST 1 2.000000 114.4000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 20 99.000000 7072.5600 71.4400
PHY-97110GT-PT SESSION BY LICENSED PT 2 12.000000 857.2800 71.4400
PHY-97110HM-PT SESSION BY PT ASST 27 142.500000 8145.3000 57.1600
PHY-97110HMGT-PT SESSION BY LICENSED PT ASST 4 12.500000 714.5000 57.1600
PHY-97110TL-PT SESSION BY LICENSED PT 4 10.000000 714.4000 71.4400
PHY-97110TLGTHM-PT SESSION BY PT ASST 3 14.000000 800.2400 57.1600
PHY-97110TLHM-PT SESSION BY PT ASST 7 33.000000 1886.2800 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 119 624.500000 44614.2800 71.4400
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 4 21.000000 1500.2400 71.4400
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 34 129.000000 9215.7600 71.4400
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 4 25.000000 1786.0000 71.4400
Subtotal (Total Children Is Unduplicated) 410 3320.750000 200390.0600 60.3448
-----------------------------------------------------------------------------------------------------------------------
Total 3589.750000 218183.5600 60.7796
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 480
-----------------------------------------------------------------------------------------------------------------------
Center 55
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 2 4.000000 261.0000 246.0000
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
3524 3585.750000 217922.5600 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 3526 3589.750000 218183.5600 246.0000