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: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
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
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 9 20.000000 1350.0000 67.5000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 11 22.000000 1650.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 15 30.000000 1665.0000 55.5000
OCTH-97165-OT EVAL LOW COMPLEXITY 1 1.000000 51.0500 51.0500
OCTH-97165GT-OT EVAL LOW COMPLEXITY 1 1.000000 51.0500 51.0500
OCTH-97166-OT EVAL MODERATE COMPLEXITY 1 1.000000 51.0500 51.0500
OCTH-97166GT-OT EVAL MODERATE COMPLEXITY 1 1.000000 51.0500 51.0500
PSTH-97161-PT EVAL LOW COMPLEXITY 1 1.000000 51.0500 51.0500
SCREEN-T1023-SCREENING 8 9.000000 400.0000 44.4444
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 3 3.000000 153.1500 51.0500
SPCH-92524-BEHAV & QUAL ANALYSIS OF VOICE AND RES 1 1.000000 51.0500 51.0500
Subtotal (Total Children Is Unduplicated) 40 96.000000 5935.4500 61.8276
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 79 427.250000 21162.5000 49.5319
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 7 21.000000 1050.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 21 80.000000 5429.4400 67.8680
OCCT-97530GT-OT SESSION BY LICENSED OT 5 13.000000 857.2800 65.9446
OCCT-97530HM-OT SESSION BY OT ASST 11 43.000000 2288.0000 53.2093
PHY-97110-PT SESSION BY LICENSED PT 22 146.250000 9608.6800 65.7004
PHY-97110GT-PT SESSION BY LICENSED PT 2 2.500000 178.6000 71.4400
PHY-97110HM-PT SESSION BY PT ASST 3 5.000000 285.8000 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 113 707.750000 47367.2400 66.9265
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 6 14.000000 1000.1600 71.4400
Subtotal (Total Children Is Unduplicated) 217 1459.750000 89227.7000 61.1253
-----------------------------------------------------------------------------------------------------------------------
Total 1555.750000 95163.1500 61.1687
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 231
-----------------------------------------------------------------------------------------------------------------------
Center 52
Flag Claims Units Chgs Paid
---------------------------------------------------------
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 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 461 885.250000 55116.3400 55116.3400
363 670.500000 40046.8100 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 824 1555.750000 95163.1500 55116.3400