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
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
OCTH-97167-OT EVAL HIGH COMPLEXITY 3 3.000000 153.1500 51.0500
OCTH-97167GT-OT EVAL HIGH COMPLEXITY 2 2.000000 102.1000 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 2 2.000000 102.1000 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 3 3.000000 153.1500 51.0500
SPCH-92523GT-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 1 1.000000 51.0500 51.0500
Subtotal (Total Children Is Unduplicated) 9 12.000000 612.6000 51.0500
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 503 3687.000000 184350.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 139 664.000000 33200.0000 50.0000
OCCT-97530GT-OT SESSION BY LICENSED OT 2 9.000000 642.9600 71.4400
PHY-97110-PT SESSION BY LICENSED PT 2 12.000000 857.2800 71.4400
PHY-97110HM-PT SESSION BY PT ASST 4 15.000000 857.4000 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 2 22.000000 1571.6800 71.4400
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 1 6.500000 464.3600 71.4400
Subtotal (Total Children Is Unduplicated) 597 4415.500000 221943.6800 50.2647
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Total 4427.500000 222556.2800 50.2668
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Number of Children (Unduplicated) With at Least One Service 600
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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
1292 4427.500000 222556.2800 222556.2800
Other 0 0.000000 0.0000 0.0000
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Total 1292 4427.500000 222556.2800 222556.2800