CMS/EIP Fiscal Report Center: 55
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: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-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 3 6.000000 450.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 7 10.384534 778.8400 75.0000
OCTF-97168-OT RE-EVAL EST PLAN CARE 4 4.000000 205.6400 51.4100
OCTH-97166-OT EVAL MODERATE COMPLEXITY 2 2.141412 110.0900 51.4100
OCTH-97167-OT EVAL HIGH COMPLEXITY 10 10.000000 514.1000 51.4100
OCTH-97167GT-OT EVAL HIGH COMPLEXITY 1 1.000000 51.4100 51.4100
PSTF-97164-PT RE-EVAL EST PLAN CARE 1 0.194515 10.0000 51.4099
PSTH-97163-PT EVAL HIGH COMPLEXITY 1 1.000000 51.4100 51.4100
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 3 2.760357 141.9100 51.4100
Subtotal (Total Children Is Unduplicated) 32 37.480818 2313.4000 61.7222
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 3 6.000000 300.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 1 3.000000 30.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 23 107.831156 7759.5300 71.9600
OCCT-97530GT-OT SESSION BY LICENSED OT 1 2.000000 143.9200 71.9600
OCCT-97530HM-OT SESSION BY OT ASST 32 327.409722 18858.8000 57.6000
PHY-97110-PT SESSION BY LICENSED PT 21 177.611726 12780.9400 71.9600
PHY-97110GT-PT SESSION BY LICENSED PT 1 1.000000 71.9600 71.9600
PHY-97110HM-PT SESSION BY PT ASST 10 58.328005 3357.3600 57.5600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 29 169.708449 12212.2200 71.9600
Subtotal (Total Children Is Unduplicated) 99 852.889058 55514.7300 65.0902
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Total 890.369876 57828.1300 64.9484
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Number of Children (Unduplicated) With at Least One Service 108
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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 259 257.750000 17251.6000 17251.6000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 1 2.000000 150.0000 0.0000
T 0 0.000000 0.0000 0.0000
656 630.619876 40426.5300 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 916 890.369876 57828.1300 17251.6000