CMS/EIP Fiscal Report Center: 05
Services beginning 01/01/2023 ending 03/31/2023 Date of Report:04/20/2023 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
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 1 1.500000 112.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
OCTH-97165-OT EVAL LOW COMPLEXITY 1 1.000000 51.4100 51.4100
OCTH-97167-OT EVAL HIGH COMPLEXITY 1 1.000000 51.4100 51.4100
PSTH-97161-PT EVAL LOW COMPLEXITY 2 2.000000 64.2600 32.1300
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
SPL-92526-TREATMENT OF SWALLOWING DYSFUNCTION 1 7.000000 370.5100 52.9300
Subtotal (Total Children Is Unduplicated) 9 16.500000 902.9100 54.7218
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1 1.000000 50.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 3 4.500000 323.8200 71.9600
PHY-97110-PT SESSION BY LICENSED PT 11 26.500000 1435.7500 54.1792
PHY-97110GT-PT SESSION BY LICENSED PT 1 7.000000 100.3800 14.3400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 4 7.000000 503.7200 71.9600
Subtotal (Total Children Is Unduplicated) 20 46.000000 2413.6700 52.4711
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Total 62.500000 3316.5800 53.0653
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Number of Children (Unduplicated) With at Least One Service 26
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Center 05
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 39 56.000000 2869.3900 2869.3900
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
3 6.500000 447.1900 447.1900
Other 0 0.000000 0.0000 0.0000
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Total 42 62.500000 3316.5800 3316.5800