CMS/EIP Fiscal Report Center: 03
Services beginning 10/01/2022 ending 12/31/2022 Date of Report:01/23/2023 Page: 1
List order: No List
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
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 2 4.000000 300.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 2 2.500000 145.5000 58.2000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 1 2.000000 111.0000 55.5000
PSTF-97164-PT RE-EVAL EST PLAN CARE 1 1.000000 51.4100 51.4100
PSTH-97162-PT EVAL MODERATE COMPLEXITY 1 1.000000 51.4100 51.4100
SPL-92526-TREATMENT OF SWALLOWING DYSFUNCTION 1 1.000000 52.9300 52.9300
Subtotal (Total Children Is Unduplicated) 9 13.500000 862.2500 63.8704
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 1 1.500000 75.0000 50.0000
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 1 1.000000 50.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 22 29.000000 1450.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 9 20.000000 1000.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 5 12.500000 862.1400 68.9712
PHY-97110-PT SESSION BY LICENSED PT 7 15.500000 1041.1800 67.1729
PHY-97110GT-PT SESSION BY LICENSED PT 2 7.000000 503.7200 71.9600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 9 22.750000 1270.5100 55.8466
Subtotal (Total Children Is Unduplicated) 55 109.250000 6252.5500 57.2316
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Total 122.750000 7114.8000 57.9617
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Number of Children (Unduplicated) With at Least One Service 63
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Center 03
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 46 50.000000 3085.1100 3085.1100
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
75 72.750000 4029.6900 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 121 122.750000 7114.8000 3085.1100