CMS/EIP Fiscal Report Center: 55
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-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 5 10.000000 750.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 3 6.000000 450.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 3 6.000000 450.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 8 16.000000 1200.0000 75.0000
OCTF-97168-OT RE-EVAL EST PLAN CARE 1 1.000000 51.4100 51.4100
OCTH-97167-OT EVAL HIGH COMPLEXITY 1 1.000000 51.0500 51.0500
PSTF-97164-PT RE-EVAL EST PLAN CARE 2 2.000000 102.4600 51.2300
PSTH-97163-PT EVAL HIGH COMPLEXITY 2 2.000000 102.1000 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 1 1.000000 51.0500 51.0500
Subtotal (Total Children Is Unduplicated) 20 45.000000 3208.0700 71.2904
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 14 92.750000 4637.5000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 17 107.750000 7720.4100 71.6511
OCCT-97530HM-OT SESSION BY OT ASST 13 118.250000 6785.1000 57.3793
PHY-97110-PT SESSION BY LICENSED PT 13 104.500000 7488.3600 71.6589
PHY-97110HM-PT SESSION BY PT ASST 6 51.000000 2920.1600 57.2580
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 27 193.750000 13878.9400 71.6332
Subtotal (Total Children Is Unduplicated) 68 668.000000 43430.4700 65.0157
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Total 713.000000 46638.5400 65.4117
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Number of Children (Unduplicated) With at Least One Service 77
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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 676 691.500000 45450.2400 45450.2400
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
23 21.500000 1188.3000 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 699 713.000000 46638.5400 45450.2400