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: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 2 3.000000 150.0000 50.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 2 2.000000 150.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 4 4.000000 222.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 3 3.500000 262.5000 75.0000
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 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 2 2.000000 102.1000 51.0500
SPCH-92523GT-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 1 1.000000 51.0500 51.0500
SPCH-92524-BEHAV & QUAL ANALYSIS OF VOICE AND RES 4 4.000000 204.2000 51.0500
Subtotal (Total Children Is Unduplicated) 20 24.500000 1397.1000 57.0245
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EI Services,Class #03
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 1 1.000000 50.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 18 73.000000 3650.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 21 72.000000 4716.2400 65.5033
OCCT-97530HM-OT SESSION BY OT ASST 20 83.000000 4691.5400 56.5246
OCCT-97530HMGT-OT SESSION BY OT ASST 1 1.000000 57.2000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 11 54.000000 3857.7600 71.4400
PHY-97110GT-PT SESSION BY LICENSED PT 1 3.000000 214.3200 71.4400
PHY-97110HM-PT SESSION BY PT ASST 4 14.500000 772.0400 53.2441
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 70 464.250000 32411.2400 69.8142
Subtotal (Total Children Is Unduplicated) 107 765.750000 50420.3400 65.8444
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Total 790.250000 51817.4400 65.5709
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Number of Children (Unduplicated) With at Least One Service 118
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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 0 0.000000 0.0000 0.0000
P 226 635.750000 41943.1900 41943.1900
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 4 12.000000 821.5600 821.5600
T 0 0.000000 0.0000 0.0000
55 142.500000 9052.6900 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 285 790.250000 51817.4400 42764.7500