CMS/EIP Fiscal Report              Center: 03 
Services beginning 10/01/2021 ending 12/31/2021                Date of Report:02/04/2022   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                       1               1.000000           51.0500           51.0500
  SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP       2               2.000000          102.1000           51.0500
Subtotal (Total Children Is Unduplicated)                  3               3.000000          153.1500           51.0500
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EI Services,Class #03
  OCCT-97530-OT SESSION BY LICENSED OT                    12              20.000000         1140.4800           57.0240
  OCCT-97530GT-OT SESSION BY LICENSED OT                   3               4.750000          294.3400           61.9663
  PHY-97110-PT SESSION BY LICENSED PT                      6              17.000000         1214.4800           71.4400
  SPL-92507-SPL THERAPY SESSION BY LICENSED SLP           12              28.000000         1827.1500           65.2554
  SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP          2               4.000000          285.7600           71.4400
Subtotal (Total Children Is Unduplicated)                 33              73.750000         4762.2100           64.5723
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Total                                                                     76.750000         4915.3600           64.0438
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Number of Children (Unduplicated) With at Least One Service         34
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Center 03
Flag      Claims          Units         Chgs         Paid
---------------------------------------------------------
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             36      35.750000    2177.6300    2177.6300 
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 
              41      41.000000    2737.7300       0.0000 
Other          0       0.000000       0.0000       0.0000 
---------------------------------------------------------
Total         77      76.750000    4915.3600    2177.6300