CMS/EIP Fiscal Report Center: 06
Services beginning 10/01/2023 ending 12/31/2023 Date of Report:01/14/2024 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-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 3 5.500000 305.2500 55.5000
Subtotal (Total Children Is Unduplicated) 3 5.500000 305.2500 55.5000
-----------------------------------------------------------------------------------------------------------------------
EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 7 33.000000 1650.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 8 46.000000 3267.6500 71.0359
OCCT-97530GT-OT SESSION BY LICENSED OT 5 22.250000 1601.1100 71.9600
OCCT-97530HM-OT SESSION BY OT ASST 6 27.250000 1470.2000 53.9523
OCCT-97530HMGT-OT SESSION BY OT ASST 3 6.500000 374.4000 57.6000
PHY-97110-PT SESSION BY LICENSED PT 14 43.250000 2887.3100 66.7586
PHY-97110GT-PT SESSION BY LICENSED PT 3 6.250000 449.7500 71.9600
PHY-97110HM-PT SESSION BY PT ASST 8 33.750000 1942.6500 57.5600
PHY-97110HMGT-PT SESSION BY LICENSED PT ASST 2 6.000000 345.3600 57.5600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 38 191.000000 13186.5700 69.0396
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 9 25.250000 1640.1600 64.9568
Subtotal (Total Children Is Unduplicated) 93 440.500000 28815.1600 65.4147
-----------------------------------------------------------------------------------------------------------------------
Total 446.000000 29120.4100 65.2924
-----------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Service 96
-----------------------------------------------------------------------------------------------------------------------
Center 06
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 281 233.250000 14904.3600 14904.3600
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
257 212.750000 14216.0500 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 538 446.000000 29120.4100 14904.3600