CMS/EIP Fiscal Report Center: 51
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-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 2 2.000000 111.0000 55.5000
OCTH-97165-OT EVAL LOW COMPLEXITY 2 2.000000 102.8200 51.4100
OCTH-97167-OT EVAL HIGH COMPLEXITY 2 2.000000 102.8200 51.4100
PSTH-97161-PT EVAL LOW COMPLEXITY 1 1.000000 51.4100 51.4100
PSTH-97162-PT EVAL MODERATE COMPLEXITY 1 1.000000 51.4100 51.4100
SPCH-92521-EVAL OF SPEECH FLUENCY 2 2.000000 102.8200 51.4100
Subtotal (Total Children Is Unduplicated) 8 10.000000 522.2800 52.2280
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 3 12.000000 600.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 2 4.000000 40.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 14 68.250000 4677.5600 68.5357
OCCT-97530GT-OT SESSION BY LICENSED OT 1 7.000000 403.2000 57.6000
OCCT-97530HM-OT SESSION BY OT ASST 9 40.000000 2304.0000 57.6000
PHY-97110-PT SESSION BY LICENSED PT 11 43.500000 3094.2800 71.1329
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 38 184.000000 12988.4600 70.5895
Subtotal (Total Children Is Unduplicated) 56 358.750000 24107.5000 67.1986
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Total 368.750000 24629.7800 66.7926
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Number of Children (Unduplicated) With at Least One Service 59
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Center 51
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 131 366.750000 24485.8600 24485.8600
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
1 2.000000 143.9200 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 132 368.750000 24629.7800 24485.8600