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:OTHER
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
PSTF-97164-PT RE-EVAL EST PLAN CARE 1 1.000000 51.4100 51.4100
Subtotal (Total Children Is Unduplicated) 1 1.000000 51.4100 51.4100
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EI Services,Class #03
OCCT-97530-OT SESSION BY LICENSED OT 1 6.000000 431.7600 71.9600
OCCT-97530HM-OT SESSION BY OT ASST 6 18.000000 1036.8000 57.6000
PHY-97110-PT SESSION BY LICENSED PT 1 3.000000 215.8800 71.9600
PHY-97110HM-PT SESSION BY PT ASST 1 3.000000 172.6800 57.5600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 6 24.000000 1727.0400 71.9600
Subtotal (Total Children Is Unduplicated) 14 54.000000 3584.1600 66.3733
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Total 55.000000 3635.5700 66.1013
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Number of Children (Unduplicated) With at Least One Service 14
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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 56 55.000000 3635.5700 3635.5700
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
0 0.000000 0.0000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 56 55.000000 3635.5700 3635.5700