CMS/EIP Fiscal Report Center: 52
Services beginning 01/01/2022 ending 03/31/2022 Date of Report:04/16/2022 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
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 13 26.000000 1950.0000 75.0000
Subtotal (Total Children Is Unduplicated) 13 26.000000 1950.0000 75.0000
-----------------------------------------------------------------------------------------------------------------------
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 3.000000 150.0000 50.0000
CONOF-CONOFGT-CONSULT,OT,FACE TO FACE 5 5.000000 250.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 2 5.000000 50.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 1 1.000000 71.4400 71.4400
OCCT-97530GT-OT SESSION BY LICENSED OT 2 2.000000 142.8800 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 1 1.000000 57.2000 57.2000
OCCT-97530TLHM-OT SESSION BY OT ASST 1 1.000000 57.2000 57.2000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 1 2.000000 142.8800 71.4400
TRAV-TRAVS-Travel by mile 1 75.000000 33.3700 0.4449
Subtotal (Total Children Is Unduplicated) 12 96.000000 1004.9700 10.4684
-----------------------------------------------------------------------------------------------------------------------
Total 122.000000 2954.9700 24.2211
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 25
-----------------------------------------------------------------------------------------------------------------------
Center 52
Flag Claims Units Chgs Paid
---------------------------------------------------------
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 2 78.000000 63.3700 63.3700
32 44.000000 2891.6000 2245.7600
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 34 122.000000 2954.9700 2309.1300