CMS/EIP Fiscal Report Center: 51
Services beginning 10/01/2022 ending 12/31/2022 Date of Report:01/23/2023 Page: 1
List order: No List
Eligibility Filter:Program Patients
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 1 1.000000 75.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 1 1.000000 75.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 1 1.000000 75.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 3 3.500000 262.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 27 27.000000 1498.5000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 6 8.000000 444.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 11 13.000000 975.0000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 5 6.500000 487.5000 75.0000
OCTH-97165-OT EVAL LOW COMPLEXITY 9 9.000000 462.6900 51.4100
OCTH-97165TL-OT EVAL LOW COMPLEXITY 1 1.000000 51.4100 51.4100
OCTH-97166-OT EVAL MODERATE COMPLEXITY 4 4.000000 205.6400 51.4100
OCTH-97167-OT EVAL HIGH COMPLEXITY 8 8.000000 411.2800 51.4100
PSTH-97161-PT EVAL LOW COMPLEXITY 3 3.000000 154.2300 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-92521-EVAL OF SPEECH FLUENCY 8 9.000000 462.6900 51.4100
SPCH-92522GT-EVAL OF SPCH SOUND PROD 1 1.000000 51.4100 51.4100
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 2 2.000000 102.8200 51.4100
SPCH-92523GT-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 1 1.000000 51.4100 51.4100
Subtotal (Total Children Is Unduplicated) 85 101.000000 5948.9000 58.9000
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 2 2.000000 100.0000 50.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 1 2.000000 100.0000 50.0000
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 7 23.000000 1150.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 112 646.500000 32275.0000 49.9227
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 3 7.000000 350.0000 50.0000
INTR-T1013-INTERPRETER 1 2.000000 60.0000 30.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 427 2710.000000 27040.0000 9.9779
OCCT-97530-OT SESSION BY LICENSED OT 94 323.250000 22592.9100 69.8930
OCCT-97530GT-OT SESSION BY LICENSED OT 9 41.750000 2573.4900 61.6405
OCCT-97530HM-OT SESSION BY OT ASST 45 187.250000 10722.9300 57.2653
OCCT-97530HMGT-OT SESSION BY OT ASST 1 4.000000 230.4000 57.6000
PHY-97110-PT SESSION BY LICENSED PT 40 200.000000 14356.0200 71.7801
PHY-97110GT-PT SESSION BY LICENSED PT 2 10.000000 719.6000 71.9600
PHY-97110TL-PT SESSION BY LICENSED PT 1 9.000000 647.6400 71.9600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 154 833.750000 59059.8100 70.8364
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 8 28.000000 2014.8800 71.9600
Subtotal (Total Children Is Unduplicated) 441 5029.500000 173992.6800 34.5944
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Total 5130.500000 179941.5800 35.0729
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Number of Children (Unduplicated) With at Least One Service 454
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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 10 14.500000 999.7500 0.0000
P 1362 3967.000000 108374.0100 108374.0100
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
389 1149.000000 70567.8200 40.0000
Other 0 0.000000 0.0000 0.0000
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Total 1761 5130.500000 179941.5800 108414.0100