CMS/EIP Fiscal Report Center: 57
Services beginning 10/01/2022 ending 12/31/2022 Date of Report:01/23/2023 Page: 1
List order: No List
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
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 13 22.500000 1687.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 2 4.000000 300.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 5 10.000000 750.0000 75.0000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 17 32.500000 1803.7500 55.5000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 3 6.000000 450.0000 75.0000
OCTF-97168-OT RE-EVAL EST PLAN CARE 1 1.000000 51.4100 51.4100
OCTH-97165-OT EVAL LOW 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 1 1.000000 51.4100 51.4100
Subtotal (Total Children Is Unduplicated) 24 79.000000 5196.8900 65.7834
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EI Services,Class #03
CONPF-CONPF-CONSULT, PT, FACE TO FACE 1 1.000000 50.0000 50.0000
CONPF-CONPFGT-CONSULT,PT,FACE TO FACE 1 1.000000 50.0000 50.0000
CONSF-CONSFGT-CONSULT,SLP,FACE TO FACE 1 1.000000 50.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 18 56.000000 2800.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 2 8.000000 400.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 23 73.000000 730.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 2 9.429129 678.5200 71.9600
PHY-97110GT-PT SESSION BY LICENSED PT 1 1.000000 71.9600 71.9600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 9 30.000000 2158.8000 71.9600
Subtotal (Total Children Is Unduplicated) 45 180.429129 6989.2800 38.7370
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Total 259.429129 12186.1700 46.9730
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Number of Children (Unduplicated) With at Least One Service 66
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Center 57
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 6 16.000000 541.9600 541.9600
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
62 133.000000 7980.5000 2989.2500
Other 48 110.429129 3663.7100 3663.7100
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Total 116 259.429129 12186.1700 7194.9200