CMS/EIP Fiscal Report Center: 55
Services beginning 10/01/2023 ending 12/31/2023 Date of Report:01/14/2024 Page: 1
List order: No List
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
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 6 10.887200 816.5400 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 4 6.072533 455.4400 75.0000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 31 56.353467 4226.5100 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 4 8.000000 600.0000 75.0000
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 1 2.000000 150.0000 75.0000
OCTF-97168-OT RE-EVAL EST PLAN CARE 2 2.000000 102.8200 51.4100
OCTH-97165-OT EVAL LOW COMPLEXITY 1 1.000000 51.4100 51.4100
OCTH-97167-OT EVAL HIGH COMPLEXITY 2 2.000000 102.8200 51.4100
PSTF-97164-PT RE-EVAL EST PLAN CARE 1 1.000000 51.4100 51.4100
PSTH-97162-PT EVAL MODERATE COMPLEXITY 1 1.000000 51.4100 51.4100
PSTH-97163-PT EVAL HIGH COMPLEXITY 1 1.000000 51.4100 51.4100
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 5 5.000000 257.0500 51.4100
Subtotal (Total Children Is Unduplicated) 58 102.313200 7366.8200 72.0026
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1 1.000000 50.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 28 143.750000 10344.2500 71.9600
OCCT-97530HM-OT SESSION BY OT ASST 20 117.424131 6763.6300 57.6000
PHY-97110-PT SESSION BY LICENSED PT 21 67.428849 4852.1800 71.9600
PHY-97110GT-PT SESSION BY LICENSED PT 1 1.000000 71.9600 71.9600
PHY-97110HM-PT SESSION BY PT ASST 16 65.647672 3778.6800 57.5600
PHY-97110HMGT-PT SESSION BY LICENSED PT ASST 1 1.000000 57.5600 57.5600
SENS-V5264-EARMOLD 1 1.000000 18.1300 18.1300
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 52 202.013370 14536.8820 71.9600
Subtotal (Total Children Is Unduplicated) 117 600.264022 40473.2720 67.4258
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Total 702.577222 47840.0920 68.0923
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Number of Children (Unduplicated) With at Least One Service 158
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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 235 239.750000 16258.8400 16258.8400
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 26 47.500000 3551.8600 0.0000
T 0 0.000000 0.0000 0.0000
428 415.327222 28029.3920 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 689 702.577222 47840.0920 16258.8400