CMS/EIP Fiscal Report Center: 52
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: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 1 2.000000 111.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 12 24.000000 1800.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 3 6.000000 450.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 12 24.000000 1800.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 33 66.000000 3663.0000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 5 10.000000 555.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 2.000000 150.0000 75.0000
OCTH-97165TLGT-OT EVAL LOW COMPLEXITY 1 1.000000 51.0500 51.0500
OCTH-97166TL-OT EVAL MODERATE COMPLEXITY 3 3.000000 153.1500 51.0500
OCTH-97167TL-OT EVAL HIGH COMPLEXITY 2 2.000000 102.1000 51.0500
PSTH-97161TL-PT EVAL LOW COMPLEXITY 1 1.000000 51.0500 51.0500
PSTH-97162GT-PT EVAL MODERATE COMPLEXITY 1 1.000000 51.0500 51.0500
PSTH-97163TL-PT EVAL HIGH COMPLEXITY 1 1.000000 51.0500 51.0500
SCREEN-T1023-SCREENING 10 10.000000 500.0000 50.0000
SPCH-92523TL-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 5 5.000000 255.2500 51.0500
Subtotal (Total Children Is Unduplicated) 66 160.000000 9893.7000 61.8356
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 187 854.000000 42700.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 11 12.000000 600.0000 50.0000
OCCT-97530TL-OT SESSION BY LICENSED OT 27 145.000000 10358.8000 71.4400
OCCT-97530TLGT-OT SESSION BY LICENSED OT 1 1.000000 71.4400 71.4400
OCCT-97530TLHM-OT SESSION BY OT ASST 12 51.750000 2960.1000 57.2000
PHY-97110TL-PT SESSION BY LICENSED PT 28 145.750000 10412.3800 71.4400
PHY-97110TLGT-PT SESSION BY LICENSED PT 2 9.250000 660.8200 71.4400
PHY-97110TLHM-PT SESSION BY PT ASST 1 0.750000 42.8700 57.1600
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 1 0.750000 53.5800 71.4400
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 92 530.250000 37881.0600 71.4400
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 9 20.000000 1428.8000 71.4400
Subtotal (Total Children Is Unduplicated) 310 1770.500000 107169.8500 60.5308
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Total 1930.500000 117063.5500 60.6390
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Number of Children (Unduplicated) With at Least One Service 341
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Center 52
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 1 1.000000 50.0000 50.0000
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
988 1929.500000 117013.5500 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 989 1930.500000 117063.5500 50.0000