CMS/EIP Fiscal Report Center: 53
Services beginning 01/01/2023 ending 03/31/2023 Date of Report:04/20/2023 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-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 3 5.000000 277.5000 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 1 1.500000 83.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 1 1.500000 112.5000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 2 3.500000 262.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 3 6.000000 450.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 5 10.000000 750.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 22 40.500000 2247.7500 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 27 51.500000 2858.2500 55.5000
Subtotal (Total Children Is Unduplicated) 66 123.500000 7341.7500 59.4474
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 198 862.500000 43125.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 124 330.000000 16500.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 5 16.000000 1151.3600 71.9600
OCCT-97530GT-OT SESSION BY LICENSED OT 2 2.000000 143.9200 71.9600
OCCT-97530TL-OT SESSION BY LICENSED OT 7 16.000000 1151.3600 71.9600
OCCT-97530TLGT-OT SESSION BY LICENSED OT 5 8.000000 575.6800 71.9600
Subtotal (Total Children Is Unduplicated) 244 1234.500000 62647.3200 50.7471
-----------------------------------------------------------------------------------------------------------------------
Total 1358.000000 69989.0700 51.5383
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 293
-----------------------------------------------------------------------------------------------------------------------
Center 53
Flag Claims Units Chgs Paid
---------------------------------------------------------
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
1301 1358.000000 69989.0700 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1301 1358.000000 69989.0700 0.0000