CMS/EIP Fiscal Report Center: 52
Services beginning 07/01/2022 ending 06/30/2023 Date of Report:07/25/2023 Page: 1
List order: No List
Agency Filter:EXT
Payclass Filters:OTHER
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-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 2 4.000000 300.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 2 4.000000 222.0000 55.5000
Subtotal (Total Children Is Unduplicated) 4 8.000000 522.0000 65.2500
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EI Services,Class #03
CONOF-CONOF-CONSULT, OT, FACE TO FACE 1 1.000000 50.0000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 1 1.000000 50.0000 50.0000
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 1 1.000000 50.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 4 8.000000 400.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 7 8.000000 80.0000 10.0000
OCCT-97530HM-OT SESSION BY OT ASST 1 1.000000 57.6000 57.6000
PHY-97110HM-PT SESSION BY PT ASST 1 4.000000 228.6400 57.1600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 2 2.000000 143.9200 71.9600
Subtotal (Total Children Is Unduplicated) 17 26.000000 1060.1600 40.7754
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Total 34.000000 1582.1600 46.5341
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Number of Children (Unduplicated) With at Least One Service 21
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Center 52
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 0 0.000000 0.0000 0.0000
T 7 13.000000 688.6400 588.6400
17 21.000000 893.5200 282.0000
Other 0 0.000000 0.0000 0.0000
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Total 24 34.000000 1582.1600 870.6400