CMS/EIP Fiscal Report Center: 52
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
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 2.000000 150.0000 75.0000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 15 30.000000 2250.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 4 8.000000 600.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 10 20.000000 1110.0000 55.5000
OCTH-97165TL-OT EVAL LOW COMPLEXITY 1 1.000000 51.4100 51.4100
OCTH-97166-OT EVAL MODERATE COMPLEXITY 1 1.000000 51.4100 51.4100
PSTH-97162TL-PT EVAL MODERATE COMPLEXITY 1 1.000000 51.4100 51.4100
SCREEN-T1023-SCREENING 5 5.000000 250.0000 50.0000
SPCH-92522TL-EVAL OF SPCH SOUND PROD 2 2.000000 102.8200 51.4100
SPCH-92523TL-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 2 2.000000 102.8200 51.4100
Subtotal (Total Children Is Unduplicated) 41 74.000000 4869.8700 65.8091
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 120 456.000000 22800.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 1 1.000000 50.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 13 37.000000 2662.5200 71.9600
OCCT-97530GT-OT SESSION BY LICENSED OT 1 0.750000 53.9700 71.9600
OCCT-97530TL-OT SESSION BY LICENSED OT 22 72.250000 5199.1100 71.9600
OCCT-97530TLGTHM-OT SESSION BY OT ASST 1 0.500000 28.8000 57.6000
OCCT-97530TLHM-OT SESSION BY OT ASST 10 56.000000 3225.6000 57.6000
PHY-97110HM-PT SESSION BY PT ASST 1 1.000000 57.5600 57.5600
PHY-97110HMGT-PT SESSION BY LICENSED PT ASST 1 1.000000 57.5600 57.5600
PHY-97110TL-PT SESSION BY LICENSED PT 27 73.750000 5307.0500 71.9600
PHY-97110TLGT-PT SESSION BY LICENSED PT 1 0.750000 53.9700 71.9600
PHY-97110TLGTHM-PT SESSION BY PT ASST 1 1.000000 57.5600 57.5600
PHY-97110TLHM-PT SESSION BY PT ASST 6 35.000000 2014.6000 57.5600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 1 2.000000 143.9200 71.9600
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 39 194.000000 13960.2400 71.9600
Subtotal (Total Children Is Unduplicated) 198 932.000000 55672.4600 59.7344
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Total 1006.000000 60542.3300 60.1812
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Number of Children (Unduplicated) With at Least One Service 225
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Center 52
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 1 2.000000 143.9200 0.0000
595 1004.000000 60398.4100 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 596 1006.000000 60542.3300 0.0000