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
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-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 1 1.000000 55.5000 55.5000
Subtotal (Total Children Is Unduplicated) 1 1.000000 55.5000 55.5000
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1 2.000000 100.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 2 7.000000 503.7200 71.9600
OCCT-97530HM-OT SESSION BY OT ASST 2 11.500000 662.4000 57.6000
PHY-97110-PT SESSION BY LICENSED PT 1 1.500000 107.9400 71.9600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 4 19.000000 827.6000 43.5579
Subtotal (Total Children Is Unduplicated) 9 41.000000 2201.6600 53.6990
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Total 42.000000 2257.1600 53.7419
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Number of Children (Unduplicated) With at Least One Service 10
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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 0 0.000000 0.0000 0.0000
P 11 30.000000 1977.2000 1977.2000
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
3 12.000000 279.9600 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 14 42.000000 2257.1600 1977.2000