CMS/EIP Fiscal Report Center: 06
Services beginning 10/01/2022 ending 12/31/2022 Date of Report:01/23/2023 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
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 11 17.500000 1227.5000 70.1429
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 7 12.000000 900.0000 75.0000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 4 5.500000 305.2500 55.5000
MED-99205-OUTPATIENT VISIT, NEW, 60 MINS 1 1.000000 50.0000 50.0000
Subtotal (Total Children Is Unduplicated) 12 36.000000 2482.7500 68.9653
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 2 3.000000 150.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 15 73.250000 4920.9000 67.1795
OCCT-97530GT-OT SESSION BY LICENSED OT 1 0.500000 28.8000 57.6000
OCCT-97530HM-OT SESSION BY OT ASST 10 64.000000 2691.1300 42.0489
OCCT-97530HMGT-OT SESSION BY OT ASST 2 6.500000 374.4000 57.6000
PHY-97110-PT SESSION BY LICENSED PT 16 70.250000 4406.8000 62.7302
PHY-97110GT-PT SESSION BY LICENSED PT 6 9.750000 676.0300 69.3364
PHY-97110HM-PT SESSION BY PT ASST 14 61.250000 3442.4000 56.2024
PHY-97110HMGT-PT SESSION BY LICENSED PT ASST 7 16.250000 877.1900 53.9809
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 40 195.250000 12890.9200 66.0226
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 29 103.500000 6864.5400 66.3241
Subtotal (Total Children Is Unduplicated) 126 603.500000 37323.1100 61.8444
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Total 639.500000 39805.8600 62.2453
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Number of Children (Unduplicated) With at Least One Service 136
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Center 06
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 223 152.250000 9233.9600 9233.9600
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
648 487.250000 30571.9000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 871 639.500000 39805.8600 9233.9600