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
Payclass Filters:TPIN
Eligibility Filter:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Screening, Eval, and Assessment,Class #02
EVAL-96111-DEVELOPMENTAL EVALUATION 3 6.000000 300.0000 50.0000
EXIT-EXIT-EXIT ASSESSMENT 1 2.000000 100.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 2.000000 150.0000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 1 2.000000 150.0000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 2 4.000000 300.0000 75.0000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 5 8.228534 617.1400 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 63 116.383467 8728.7600 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 3 6.000000 450.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 23 41.306267 3097.9700 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 10 19.999999 1500.0000 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 2 2.180180 121.0000 55.5000
OCTF-97168-OT RE-EVAL EST PLAN CARE 3 2.460725 125.6200 51.0500
OCTF-97168GT-OT RE-EVAL EST PLAN CARE 2 2.000000 102.1000 51.0500
OCTH-97166-OT EVAL MODERATE COMPLEXITY 1 1.000000 51.0500 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 7 7.000000 357.3500 51.0500
OCTH-97167GT-OT EVAL HIGH COMPLEXITY 1 1.000000 51.0500 51.0500
PSTH-97163GT-PT EVAL HIGH COMPLEXITY 1 1.000000 51.0500 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 9 9.000000 459.4500 51.0500
SPCH-92610-EVAL OF ORAL,PHARYNGEAL SWALLOWING FUNC 1 1.000000 48.9400 48.9400
Subtotal (Total Children Is Unduplicated) 99 236.559172 16872.4800 71.3246
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EI Services,Class #03
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 1 1.000000 50.0000 50.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 2 4.000000 200.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 5 10.000000 500.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 9 12.000000 120.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 25 134.175955 9603.3900 71.5731
OCCT-97530GT-OT SESSION BY LICENSED OT 4 13.000000 928.7200 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 24 189.738289 10853.0300 57.2000
OCCT-97530HMGT-OT SESSION BY OT ASST 8 68.684090 3928.7300 57.2000
PHY-97110-PT SESSION BY LICENSED PT 9 51.556830 3683.2200 71.4400
PHY-97110GT-PT SESSION BY LICENSED PT 2 2.000000 142.8800 71.4400
PHY-97110HM-PT SESSION BY PT ASST 11 83.888908 4795.0900 57.1600
PHY-97110HMGT-PT SESSION BY LICENSED PT ASST 4 20.010322 1143.7900 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 55 283.473400 20251.3400 71.4400
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 4 33.821394 2416.2000 71.4400
Subtotal (Total Children Is Unduplicated) 112 907.349188 58616.3900 64.6018
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Total 1143.908360 75488.8700 65.9921
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Number of Children (Unduplicated) With at Least One Service 183
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Center 55
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 406 407.968159 27142.4600 27142.4600
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 46 80.500000 5929.7300 0.0000
T 0 0.000000 0.0000 0.0000
703 655.440201 42416.6800 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 1155 1143.908360 75488.8700 27142.4600