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
Payclass Filters:GR
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-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 22 22.000000 1221.0000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 3 3.500000 194.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 3 3.000000 225.0000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 2 3.000000 225.0000 75.0000
OCTH-97165-OT EVAL LOW COMPLEXITY 3 3.000000 154.2300 51.4100
OCTH-97166-OT EVAL MODERATE COMPLEXITY 2 2.000000 102.8200 51.4100
OCTH-97167-OT EVAL HIGH COMPLEXITY 5 5.000000 257.0500 51.4100
PSTH-97161-PT EVAL LOW 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 4 4.000000 205.6400 51.4100
SPCH-92522GT-EVAL OF SPCH SOUND PROD 1 1.000000 51.4100 51.4100
Subtotal (Total Children Is Unduplicated) 43 50.500000 2889.2200 57.2123
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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 30 153.500000 7625.0000 49.6743
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 1 2.000000 100.0000 50.0000
INTR-T1013-INTERPRETER 1 2.000000 60.0000 30.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 427 2706.000000 27000.0000 9.9778
OCCT-97530-OT SESSION BY LICENSED OT 25 135.000000 9280.1500 68.7419
OCCT-97530GT-OT SESSION BY LICENSED OT 4 25.000000 1468.6800 58.7472
OCCT-97530HM-OT SESSION BY OT ASST 20 94.250000 5366.1300 56.9351
OCCT-97530HMGT-OT SESSION BY OT ASST 1 4.000000 230.4000 57.6000
PHY-97110-PT SESSION BY LICENSED PT 19 82.000000 5900.7200 71.9600
PHY-97110GT-PT SESSION BY LICENSED PT 1 4.000000 287.8400 71.9600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 67 325.000000 22702.3400 69.8534
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 2 5.000000 359.8000 71.9600
Subtotal (Total Children Is Unduplicated) 431 3564.750000 81731.0600 22.9276
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Total 3615.250000 84620.2800 23.4065
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Number of Children (Unduplicated) With at Least One Service 435
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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 0 0.000000 0.0000 0.0000
P 1231 3600.250000 83888.1500 83888.1500
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
8 15.000000 732.1300 40.0000
Other 0 0.000000 0.0000 0.0000
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Total 1239 3615.250000 84620.2800 83928.1500