CMS/EIP Fiscal Report Center: 02
Services beginning 10/01/2021 ending 12/31/2021 Date of Report:02/04/2022 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
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 6 10.500000 787.5000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 13 26.000000 1950.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 6 11.000000 610.5000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 1 2.000000 111.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 2.000000 150.0000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 3 4.500000 337.5000 75.0000
OCTH-97165-OT EVAL LOW COMPLEXITY 4 4.000000 204.2000 51.0500
OCTH-97166-OT EVAL MODERATE COMPLEXITY 1 1.000000 51.0500 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 1 1.000000 51.0500 51.0500
PSTH-97162-PT EVAL MODERATE COMPLEXITY 1 1.000000 21.1400 21.1400
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 7 7.000000 357.3500 51.0500
Subtotal (Total Children Is Unduplicated) 37 70.000000 4631.2900 66.1613
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 2 2.000000 629.4600 314.7300
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 65 466.000000 23300.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 16 63.000000 3150.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 20 94.750000 5755.5500 60.7446
OCCT-97530GT-OT SESSION BY LICENSED OT 2 13.500000 402.0400 29.7807
PHY-97110-PT SESSION BY LICENSED PT 14 56.750000 2378.1900 41.9064
PHY-97110GT-PT SESSION BY LICENSED PT 4 16.500000 995.7800 60.3503
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 43 228.750000 15282.3700 66.8082
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 9 34.250000 2446.8200 71.4400
Subtotal (Total Children Is Unduplicated) 111 975.500000 54340.2100 55.7050
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Total 1045.500000 58971.5000 56.4051
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Number of Children (Unduplicated) With at Least One Service 132
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Center 02
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 4 3.500000 185.7200 185.7200
H 0 0.000000 0.0000 0.0000
T 1235 1024.750000 57606.8400 57479.8400
14 17.250000 1178.9400 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 1253 1045.500000 58971.5000 57665.5600