CMS/EIP Fiscal Report Center: 51
Services beginning 10/01/2023 ending 12/31/2023 Date of Report:01/14/2024 Page: 1
List order: No List
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-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 1.000000 75.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 10 9.000000 499.5000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 1 1.000000 55.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 5 5.000000 375.0000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 4 4.500000 337.5000 75.0000
OCTH-97165-OT EVAL LOW COMPLEXITY 4 4.000000 205.6400 51.4100
PSTH-97162-PT EVAL MODERATE COMPLEXITY 1 1.000000 51.4100 51.4100
Subtotal (Total Children Is Unduplicated) 26 25.500000 1599.5500 62.7275
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 74 394.000000 19624.0000 49.8071
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 2 8.000000 400.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 30 140.500000 10110.4400 71.9604
OCCT-97530GT-OT SESSION BY LICENSED OT 2 6.000000 431.7600 71.9600
OCCT-97530HM-OT SESSION BY OT ASST 18 114.500000 6541.6000 57.1319
OCCT-97530HMGT-OT SESSION BY OT ASST 1 2.000000 115.2000 57.6000
OCCT-97530TL-OT SESSION BY LICENSED OT 1 5.250000 377.7900 71.9600
OCCT-97530TLHM-OT SESSION BY OT ASST 2 6.000000 345.6000 57.6000
PHY-97110-PT SESSION BY LICENSED PT 11 37.000000 2590.5600 70.0151
PHY-97110GT-PT SESSION BY LICENSED PT 1 1.000000 71.9600 71.9600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 29 212.000000 15255.5200 71.9600
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 2 7.000000 503.7200 71.9600
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 1 6.000000 431.7600 71.9600
Subtotal (Total Children Is Unduplicated) 140 939.250000 56799.9100 60.4737
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Total 964.750000 58399.4600 60.5333
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Number of Children (Unduplicated) With at Least One Service 158
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Center 51
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 8 7.000000 388.5000 0.0000
P 1 2.000000 100.0000 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
302 955.750000 57910.9600 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 311 964.750000 58399.4600 0.0000