CMS/EIP Fiscal Report Center: 05
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 2 2.000000 102.1000 51.0500
PSTH-97162-PT EVAL MODERATE COMPLEXITY 1 1.000000 51.0500 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 1 1.000000 51.0500 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 1 1.000000 51.0500 51.0500
Subtotal (Total Children Is Unduplicated) 4 5.000000 255.2500 51.0500
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 8 30.250000 1512.5000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 1 4.000000 200.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 1 1.000000 10.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 12 32.000000 1751.6600 54.7394
PHY-97110-PT SESSION BY LICENSED PT 18 66.250000 3529.1500 53.2702
PHY-97110GT-PT SESSION BY LICENSED PT 1 1.000000 71.4400 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 30 127.500000 6917.4300 54.2544
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 2 2.750000 196.4600 71.4400
Subtotal (Total Children Is Unduplicated) 62 264.750000 14188.6400 53.5926
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Total 269.750000 14443.8900 53.5455
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Number of Children (Unduplicated) With at Least One Service 63
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Center 05
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 119 233.750000 12131.2400 12131.2400
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
12 36.000000 2312.6500 2312.6500
Other 0 0.000000 0.0000 0.0000
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Total 131 269.750000 14443.8900 14443.8900