CMS/EIP Fiscal Report Center: 55
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:OTHER
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-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 1 2.000000 150.0000 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-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 6 12.000000 900.0000 75.0000
OCTF-97168-OT RE-EVAL EST PLAN CARE 2 2.000000 102.1000 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 3 3.000000 153.1500 51.0500
PSTF-97164-PT RE-EVAL EST PLAN CARE 2 2.000000 102.1000 51.0500
PSTH-97162-PT EVAL MODERATE COMPLEXITY 1 1.000000 51.0500 51.0500
Subtotal (Total Children Is Unduplicated) 16 30.000000 2058.4000 68.6133
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 5 18.000000 900.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 17 92.500000 6608.2000 71.4400
OCCT-97530GT-OT SESSION BY LICENSED OT 2 4.000000 285.7600 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 8 34.000000 1944.8000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 11 68.000000 4857.9200 71.4400
PHY-97110HM-PT SESSION BY PT ASST 5 30.250000 1729.0900 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 28 158.750000 11341.1000 71.4400
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 4 16.000000 1143.0400 71.4400
Subtotal (Total Children Is Unduplicated) 60 421.500000 28809.9100 68.3509
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Total 451.500000 30868.3100 68.3683
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Number of Children (Unduplicated) With at Least One Service 62
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Center 55
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 362 369.500000 25486.4100 25486.4100
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
80 82.000000 5381.9000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 442 451.500000 30868.3100 25486.4100