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
Payclass Filters:OTHER
Eligibility Filter:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Screening, Eval, and Assessment,Class #02
OCTH-97165GT-OT EVAL LOW COMPLEXITY 1 1.000000 51.0500 51.0500
Subtotal (Total Children Is Unduplicated) 1 1.000000 51.0500 51.0500
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EI Services,Class #03
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 1 1.000000 50.0000 50.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 2 1.500000 75.0000 50.0000
CONPF-CONPFGT-CONSULT,PT,FACE TO FACE 1 0.750000 18.7500 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 7 8.000000 400.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 4 5.000000 50.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 1 1.000000 71.4400 71.4400
PHY-97110-PT SESSION BY LICENSED PT 1 1.000000 71.4400 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 1 2.000000 142.8800 71.4400
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 2 2.000000 142.8800 71.4400
Subtotal (Total Children Is Unduplicated) 20 22.250000 1022.3900 45.9501
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Total 23.250000 1073.4400 46.1695
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Number of Children (Unduplicated) With at Least One Service 21
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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 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
22 23.250000 1073.4400 18.7500
Other 0 0.000000 0.0000 0.0000
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Total 22 23.250000 1073.4400 18.7500