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: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
OCTH-97167-OT EVAL HIGH COMPLEXITY 5 5.000000 255.2500 51.0500
OCTH-97167GT-OT EVAL HIGH COMPLEXITY 4 4.000000 204.2000 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 2 2.000000 102.1000 51.0500
PSTH-97163GT-PT EVAL HIGH COMPLEXITY 2 2.000000 102.1000 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 6 6.000000 306.3000 51.0500
SPCH-92523GT-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 2 2.000000 102.1000 51.0500
Subtotal (Total Children Is Unduplicated) 19 21.000000 1072.0500 51.0500
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 207 1299.000000 64950.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 73 327.750000 16387.5000 50.0000
OCCT-97530GT-OT SESSION BY LICENSED OT 2 6.000000 428.6400 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 2 2.000000 114.4000 57.2000
OCCT-97530HMGT-OT SESSION BY OT ASST 3 13.000000 743.6000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 2 5.000000 357.2000 71.4400
PHY-97110GT-PT SESSION BY LICENSED PT 2 8.500000 607.2400 71.4400
PHY-97110HM-PT SESSION BY PT ASST 3 17.000000 971.7200 57.1600
PHY-97110HMGT-PT SESSION BY LICENSED PT ASST 2 6.500000 371.5400 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 12 67.500000 4822.2000 71.4400
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 12 54.500000 3893.4800 71.4400
Subtotal (Total Children Is Unduplicated) 265 1806.750000 93647.5200 51.8320
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Total 1827.750000 94719.5700 51.8230
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Number of Children (Unduplicated) With at Least One Service 268
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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 1 1.000000 50.0000 50.0000
H 0 0.000000 0.0000 0.0000
T 549 1680.250000 85776.1200 85776.1200
63 146.500000 8893.4500 8893.4500
Other 0 0.000000 0.0000 0.0000
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Total 613 1827.750000 94719.5700 94719.5700