CMS/EIP Fiscal Report Center: 03
Services beginning 07/01/2022 ending 06/30/2023 Date of Report:07/25/2023 Page: 1
List order: No List
Agency Filter:EIP DEI DEIP
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-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 6 9.500000 712.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 9 15.000000 1125.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 2 4.000000 222.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 19 32.500000 2437.5000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 1.000000 75.0000 75.0000
Subtotal (Total Children Is Unduplicated) 30 62.000000 4572.0000 73.7419
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EI Services,Class #03
OCCT-97530GT-OT SESSION BY LICENSED OT 2 2.000000 142.8800 71.4400
PHY-97110-PT SESSION BY LICENSED PT 8 15.750000 1125.1800 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 8 14.000000 1000.1600 71.4400
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 2 2.000000 142.8800 71.4400
Subtotal (Total Children Is Unduplicated) 18 33.750000 2411.1000 71.4400
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Total 95.750000 6983.1000 72.9305
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Number of Children (Unduplicated) With at Least One Service 48
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Center 03
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 1 1.500000 112.5000 112.5000
T 0 0.000000 0.0000 0.0000
70 94.250000 6870.6000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 71 95.750000 6983.1000 112.5000