CMS/EIP Fiscal Report Center: 57
Services beginning 10/01/2020 ending 12/31/2020 Date of Report:01/23/2021 Page: 1
List order: No List
Payclass Filters:LEA
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
OCTH-97167-OT EVAL HIGH COMPLEXITY 1 1.000000 51.0500 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 1 1.000000 51.0500 51.0500
Subtotal (Total Children Is Unduplicated) 2 2.000000 102.1000 51.0500
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EI Services,Class #03
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 11 216.000000 5400.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 2 10.000000 500.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 7 39.000000 1950.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 2 2.000000 142.8800 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 4 27.000000 1544.4000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 4 11.000000 785.8400 71.4400
PHY-97110HM-PT SESSION BY PT ASST 3 32.500000 1857.7000 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 5 18.000000 1285.9200 71.4400
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 4 28.500000 1630.2000 57.2000
Subtotal (Total Children Is Unduplicated) 23 384.000000 15096.9400 39.3149
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Total 386.000000 15199.0400 39.3758
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Number of Children (Unduplicated) With at Least One Service 23
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Center 57
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
65 386.000000 15199.0400 15199.0400
Other 0 0.000000 0.0000 0.0000
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Total 65 386.000000 15199.0400 15199.0400