CMS/EIP Fiscal Report Center: 57
Services beginning 01/01/2022 ending 03/31/2022 Date of Report:04/16/2022 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-92582-CONDITIONED PLAY AUDIOMETRY 1 1.000000 63.1400 63.1400
OCTH-97165-OT EVAL LOW COMPLEXITY 2 2.000000 102.1000 51.0500
OCTH-97167-OT EVAL HIGH COMPLEXITY 5 5.000000 255.2500 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 3 3.000000 153.1500 51.0500
Subtotal (Total Children Is Unduplicated) 17 19.000000 982.0400 51.6863
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1 7.000000 350.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 3 11.000000 785.8400 71.4400
OCCT-97530HM-OT SESSION BY OT ASST 6 23.000000 1315.6000 57.2000
PHY-97110GT-PT SESSION BY LICENSED PT 2 5.000000 357.2000 71.4400
PHY-97110HM-PT SESSION BY PT ASST 1 8.000000 457.2800 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 11 56.000000 4000.6400 71.4400
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 3 7.500000 535.8000 71.4400
SPL-92507HMGT-SPL THERAPY SESSION BY SLP ASST 1 7.000000 400.4000 57.2000
Subtotal (Total Children Is Unduplicated) 28 124.500000 8202.7600 65.8856
-----------------------------------------------------------------------------------------------------------------------
Total 143.500000 9184.8000 64.0056
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 37
-----------------------------------------------------------------------------------------------------------------------
Center 57
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 2 2.000000 102.1000 102.1000
H 0 0.000000 0.0000 0.0000
T 21 46.000000 2848.8800 2848.8800
42 94.500000 6182.7700 6182.7700
Other 1 1.000000 51.0500 51.0500
---------------------------------------------------------
Total 66 143.500000 9184.8000 9184.8000