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
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
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 3 6.000000 333.0000 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 1 2.000000 111.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 8 16.000000 1200.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 7 14.000000 1050.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 2 4.000000 300.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 9 18.000000 1350.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 5 10.000000 750.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 11 22.000000 1221.0000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 3 6.000000 333.0000 55.5000
OCTF-97168-OT RE-EVAL EST PLAN CARE 14 15.000000 771.1500 51.4100
OCTH-97167-OT EVAL HIGH COMPLEXITY 12 12.000000 616.9200 51.4100
OCTH-97167GT-OT EVAL HIGH COMPLEXITY 1 1.000000 51.4100 51.4100
OCTH-97167TLGT-OT EVAL HIGH COMPLEXITY 1 2.000000 102.8200 51.4100
PSTF-97164-PT RE-EVAL EST PLAN CARE 2 2.000000 102.8200 51.4100
PSTH-97163-PT EVAL HIGH COMPLEXITY 2 2.000000 102.8200 51.4100
PSTH-97163GT-PT EVAL HIGH COMPLEXITY 1 1.000000 51.4100 51.4100
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 7 7.000000 359.8700 51.4100
Subtotal (Total Children Is Unduplicated) 81 146.000000 9257.2200 63.4056
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 162 1146.000000 57300.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 12 78.500000 3925.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 53 299.500000 21552.0200 71.9600
OCCT-97530GT-OT SESSION BY LICENSED OT 1 8.000000 575.6800 71.9600
OCCT-97530HM-OT SESSION BY OT ASST 76 539.250000 31060.8000 57.6000
OCCT-97530HMGT-OT SESSION BY OT ASST 1 4.000000 230.4000 57.6000
OCCT-97530TLHM-OT SESSION BY OT ASST 2 26.000000 1497.6000 57.6000
PHY-97110-PT SESSION BY LICENSED PT 29 199.000000 14320.0400 71.9600
PHY-97110GT-PT SESSION BY LICENSED PT 1 7.000000 503.7200 71.9600
PHY-97110HM-PT SESSION BY PT ASST 42 282.750000 16275.0900 57.5600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 87 472.500000 34001.1000 71.9600
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 1 7.000000 503.7200 71.9600
Subtotal (Total Children Is Unduplicated) 368 3069.500000 181745.1700 59.2100
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Total 3215.500000 191002.3900 59.4005
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Number of Children (Unduplicated) With at Least One Service 404
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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 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
3169 3215.500000 191002.3900 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 3169 3215.500000 191002.3900 0.0000