CMS/EIP Fiscal Report Center: 51
Services beginning 10/01/2021 ending 12/31/2021 Date of Report:02/04/2022 Page: 1
List order: No List
Eligibility Filter:Not Part C
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 9 11.000000 825.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 1 1.000000 75.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 1 1.000000 75.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 19 20.500000 1014.3800 49.4820
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 5 5.000000 375.0000 75.0000
Subtotal (Total Children Is Unduplicated) 26 38.500000 2364.3800 61.4125
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EI Services,Class #03
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 12 27.000000 270.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 1 4.000000 285.7600 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 1 2.000000 142.8800 71.4400
Subtotal (Total Children Is Unduplicated) 12 33.000000 698.6400 21.1709
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Total 71.500000 3063.0200 42.8394
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Number of Children (Unduplicated) With at Least One Service 29
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Center 51
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 5 5.500000 393.0000 0.0000
P 25 35.500000 825.3800 825.3800
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
25 30.500000 1844.6400 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 55 71.500000 3063.0200 825.3800