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
Agency Filter:EXT
Payclass Filters:MED
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-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 1 1.000000 75.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 1 1.000000 75.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 1 1.000000 55.5000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 1 1.000000 55.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 3 3.000000 225.0000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 2 2.000000 150.0000 75.0000
OCTH-97165-OT EVAL LOW COMPLEXITY 4 4.000000 205.6400 51.4100
OCTH-97165TL-OT EVAL LOW COMPLEXITY 1 1.000000 51.4100 51.4100
OCTH-97166-OT EVAL MODERATE COMPLEXITY 2 2.000000 102.8200 51.4100
OCTH-97167-OT EVAL HIGH COMPLEXITY 1 1.000000 51.4100 51.4100
PSTH-97161-PT EVAL LOW COMPLEXITY 1 1.000000 51.4100 51.4100
SPCH-92521-EVAL OF SPEECH FLUENCY 2 3.000000 154.2300 51.4100
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 2 2.000000 102.8200 51.4100
Subtotal (Total Children Is Unduplicated) 21 23.000000 1355.7400 58.9452
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 82 481.000000 24050.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 2 5.000000 250.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 58 120.000000 8635.2000 71.9600
OCCT-97530GT-OT SESSION BY LICENSED OT 4 9.750000 701.6100 71.9600
OCCT-97530HM-OT SESSION BY OT ASST 16 53.000000 3052.8000 57.6000
PHY-97110-PT SESSION BY LICENSED PT 17 74.500000 5361.0200 71.9600
PHY-97110GT-PT SESSION BY LICENSED PT 1 6.000000 431.7600 71.9600
PHY-97110TL-PT SESSION BY LICENSED PT 1 9.000000 647.6400 71.9600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 56 324.750000 23369.0100 71.9600
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 6 23.000000 1655.0800 71.9600
Subtotal (Total Children Is Unduplicated) 200 1106.000000 68154.1200 61.6222
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Total 1129.000000 69509.8600 61.5676
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Number of Children (Unduplicated) With at Least One Service 212
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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 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 0 0.000000 0.0000 0.0000
377 1129.000000 69509.8600 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 377 1129.000000 69509.8600 0.0000