CMS/EIP Fiscal Report Center: 57
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
OCTH-97167-OT EVAL HIGH COMPLEXITY 6 6.000000 306.3000 51.0500
OCTH-97167GT-OT EVAL HIGH COMPLEXITY 1 1.000000 51.0500 51.0500
PSTH-97163-PT EVAL HIGH COMPLEXITY 1 1.000000 51.0500 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 6 6.000000 306.3000 51.0500
SPCH-92523GT-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 1 1.000000 51.0500 51.0500
Subtotal (Total Children Is Unduplicated) 12 15.000000 765.7500 51.0500
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 643 5501.500000 275075.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 50 267.750000 13387.5000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 12 52.000000 3714.8800 71.4400
OCCT-97530GT-OT SESSION BY LICENSED OT 1 1.000000 71.4400 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 7 20.000000 1144.0000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 2 3.500000 250.0400 71.4400
PHY-97110GT-PT SESSION BY LICENSED PT 1 2.000000 142.8800 71.4400
PHY-97110HM-PT SESSION BY PT ASST 12 66.500000 3801.1400 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 11 41.750000 2982.6200 71.4400
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 6 25.500000 1458.6000 57.2000
Subtotal (Total Children Is Unduplicated) 688 5981.500000 302028.1000 50.4937
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Total 5996.500000 302793.8500 50.4951
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Number of Children (Unduplicated) With at Least One Service 690
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Center 57
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 1 1.000000 51.0500 51.0500
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
1672 5995.500000 302742.8000 302770.8000
Other 0 0.000000 0.0000 0.0000
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Total 1673 5996.500000 302793.8500 302821.8500