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
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-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 3 3.500000 194.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 15 21.000000 1575.0000 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 2 2.000000 150.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 39 43.000000 2386.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 18 21.000000 1575.0000 75.0000
OCTH-97166-OT EVAL MODERATE COMPLEXITY 1 1.000000 51.0500 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 4 4.000000 204.2000 51.0500
PSTH-97162-PT EVAL MODERATE COMPLEXITY 1 1.000000 51.0500 51.0500
PSTH-97162GT-PT EVAL MODERATE COMPLEXITY 1 1.000000 51.0500 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 2 2.000000 102.1000 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 1 1.000000 51.0500 51.0500
SPCH-92523GT-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 1 1.000000 51.0500 51.0500
SPCH-92610-EVAL OF ORAL,PHARYNGEAL SWALLOWING FUNC 1 1.000000 44.5500 44.5500
Subtotal (Total Children Is Unduplicated) 68 103.500000 6561.8500 63.3995
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 123 900.000000 44800.0000 49.7778
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 1 11.000000 550.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 53 142.250000 10162.3400 71.4400
OCCT-97530GT-OT SESSION BY LICENSED OT 2 7.250000 517.9400 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 21 60.000000 3431.7300 57.1955
OCCT-97530HMGT-OT SESSION BY OT ASST 2 5.000000 286.0000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 21 163.250000 11662.5800 71.4400
PHY-97110HM-PT SESSION BY PT ASST 9 22.500000 1286.1000 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 82 439.000000 31362.1600 71.4400
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 1 7.000000 500.0800 71.4400
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 1 8.000000 571.5200 71.4400
SPL-92508HA-GROUP SPL SESSION PER CHILD 1 1.000000 13.8800 13.8800
Subtotal (Total Children Is Unduplicated) 245 1766.250000 105144.3300 59.5297
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Total 1869.750000 111706.1800 59.7439
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Number of Children (Unduplicated) With at Least One Service 285
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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 23 30.000000 2045.2500 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
687 1839.750000 109660.9300 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 710 1869.750000 111706.1800 0.0000