CMS/EIP Fiscal Report Center: 55
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
EVAL-96111-DEVELOPMENTAL EVALUATION 2 3.000000 150.0000 50.0000
EXIT-EXIT-EXIT ASSESSMENT 4 7.000000 350.0000 50.0000
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 19 34.105734 2557.9300 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 3 6.000000 450.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 4 6.666667 500.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
OCTF-97168-OT RE-EVAL EST PLAN CARE 5 4.505738 231.6400 51.4100
OCTH-97166-OT EVAL MODERATE COMPLEXITY 1 1.000000 51.4100 51.4100
OCTH-97167-OT EVAL HIGH COMPLEXITY 9 9.000000 462.6900 51.4100
PSTF-97164-PT RE-EVAL EST PLAN CARE 3 3.000000 154.2300 51.4100
PSTH-97163-PT EVAL HIGH COMPLEXITY 1 1.000000 51.4100 51.4100
SPCH-92521-EVAL OF SPEECH FLUENCY 1 1.000000 51.4100 51.4100
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 2 2.000000 102.8200 51.4100
Subtotal (Total Children Is Unduplicated) 46 84.278139 5563.5400 66.0140
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EI Services,Class #03
OCCT-97530-OT SESSION BY LICENSED OT 28 148.120066 10658.7200 71.9600
OCCT-97530HM-OT SESSION BY OT ASST 35 316.079860 18206.2000 57.6000
PHY-97110-PT SESSION BY LICENSED PT 18 148.105052 10657.6400 71.9600
PHY-97110HM-PT SESSION BY PT ASST 8 44.040131 2534.9500 57.5600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 38 169.616303 12205.5900 71.9600
Subtotal (Total Children Is Unduplicated) 105 825.961412 54263.1000 65.6969
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Total 910.239551 59826.6400 65.7263
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Number of Children (Unduplicated) With at Least One Service 127
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Center 55
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 248 250.000000 16172.8500 16172.8500
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 38 52.500000 3676.5900 0.0000
T 0 0.000000 0.0000 0.0000
661 607.739551 39977.2000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 947 910.239551 59826.6400 16172.8500