CMS/EIP Fiscal Report Center: 53
Services beginning 04/01/2023 ending 06/30/2023 Date of Report:07/25/2023 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-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 2 3.500000 262.5000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 1 1.500000 112.5000 75.0000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 4 6.000000 333.0000 55.5000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 8 15.500000 1162.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 10 17.500000 1312.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 4 7.500000 562.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 14 25.500000 1415.2500 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 33 55.500000 3080.2500 55.5000
Subtotal (Total Children Is Unduplicated) 69 132.500000 8241.0000 62.1962
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 187 841.000000 42050.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 152 353.000000 17650.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 24 84.000000 6044.6400 71.9600
OCCT-97530GT-OT SESSION BY LICENSED OT 12 23.000000 1633.1200 71.0052
OCCT-97530TL-OT SESSION BY LICENSED OT 15 37.000000 2662.5200 71.9600
OCCT-97530TLGT-OT SESSION BY LICENSED OT 2 2.000000 143.9200 71.9600
Subtotal (Total Children Is Unduplicated) 262 1340.000000 70184.2000 52.3763
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Total 1472.500000 78425.2000 53.2599
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Number of Children (Unduplicated) With at Least One Service 313
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Center 53
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 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
1418 1472.500000 78425.2000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 1418 1472.500000 78425.2000 0.0000