CMS/EIP Fiscal Report Center: 53
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-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 11 22.000000 1221.0000 55.5000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 12 20.500000 1537.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 1 2.000000 111.0000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 39 71.000000 3940.5000 55.5000
Subtotal (Total Children Is Unduplicated) 63 115.500000 6810.0000 58.9610
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 53 126.500000 6325.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 203 929.750000 46487.5000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 5 7.000000 500.0800 71.4400
OCCT-97530TLGT-OT SESSION BY LICENSED OT 9 31.250000 2232.5000 71.4400
PHY-97110GT-PT SESSION BY LICENSED PT 1 1.000000 71.4400 71.4400
Subtotal (Total Children Is Unduplicated) 237 1095.500000 55616.5200 50.7682
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Total 1211.000000 62426.5200 51.5496
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Number of Children (Unduplicated) With at Least One Service 285
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Center 53
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
1174 1211.000000 62426.5200 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 1174 1211.000000 62426.5200 0.0000