CMS/EIP Fiscal Report Center: 53
Services beginning 07/01/2021 ending 09/30/2021 Date of Report:10/13/2021 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-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 1 1.500000 112.5000 75.0000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 7 14.000000 777.0000 55.5000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 4 6.500000 487.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 7 11.500000 862.5000 75.0000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 23 41.500000 2303.2500 55.5000
OCTF-97168-OT RE-EVAL EST PLAN CARE 1 2.000000 102.1000 51.0500
Subtotal (Total Children Is Unduplicated) 41 79.000000 4794.8500 60.6943
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 16 28.250000 1412.5000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 172 771.500000 38562.0000 49.9831
OCCT-97530-OT SESSION BY LICENSED OT 3 3.750000 267.9000 71.4400
OCCT-97530GT-OT SESSION BY LICENSED OT 6 12.750000 910.8600 71.4400
OCCT-97530TL-OT SESSION BY LICENSED OT 1 1.000000 71.4400 71.4400
OCCT-97530TLGT-OT SESSION BY LICENSED OT 11 23.000000 1643.1200 71.4400
PHY-97110-PT SESSION BY LICENSED PT 2 6.000000 428.6400 71.4400
PHY-97110GT-PT SESSION BY LICENSED PT 5 6.000000 428.6400 71.4400
Subtotal (Total Children Is Unduplicated) 194 852.250000 43725.1000 51.3055
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Total 931.250000 48519.9500 52.1020
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Number of Children (Unduplicated) With at Least One Service 223
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Center 53
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
902 931.250000 48519.9500 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 902 931.250000 48519.9500 0.0000