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: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
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 1 1.000000 9.0800 9.0800
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 1 1.000000 27.8300 27.8300
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 1 1.000000 16.7000 16.7000
OCTH-97166GT-OT EVAL MODERATE COMPLEXITY 1 1.000000 51.0500 51.0500
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 11 11.000000 561.5500 51.0500
SPCH-92523GT-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 2 3.000000 153.1500 51.0500
Subtotal (Total Children Is Unduplicated) 21 26.000000 1227.7600 47.2215
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 269 1701.500000 85075.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 23 127.250000 6362.5000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 4 12.000000 857.2800 71.4400
OCCT-97530GT-OT SESSION BY LICENSED OT 4 10.500000 750.1200 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 7 39.000001 2230.8000 57.2000
PHY-97110-PT SESSION BY LICENSED PT 1 3.000000 214.3200 71.4400
PHY-97110GT-PT SESSION BY LICENSED PT 2 9.000035 642.9600 71.4397
PHY-97110HM-PT SESSION BY PT ASST 5 33.000000 1886.2800 57.1600
PHY-97110HMGT-PT SESSION BY LICENSED PT ASST 1 2.000000 114.3200 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 15 87.000015 6215.2800 71.4400
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 3 8.500000 607.2400 71.4400
Subtotal (Total Children Is Unduplicated) 293 2032.750051 104956.1000 51.6326
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Total 2058.750051 106183.8600 51.5769
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Number of Children (Unduplicated) With at Least One Service 299
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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 8 3.140472 219.4300 219.4300
D 0 0.000000 0.0000 0.0000
S 4 4.000000 204.2000 204.2000
H 0 0.000000 0.0000 0.0000
T 573 1938.109579 98896.0100 98896.0100
47 113.500000 6864.2200 6864.2200
Other 0 0.000000 0.0000 0.0000
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Total 632 2058.750051 106183.8600 106183.8600