CMS/EIP Fiscal Report Center: 55
Services beginning 10/01/2022 ending 12/31/2022 Date of Report:01/23/2023 Page: 1
List order: No List
Agency Filter:EXT
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
EVAL-96111-DEVELOPMENTAL EVALUATION 1 2.000000 100.0000 50.0000
EXIT-EXIT-EXIT ASSESSMENT 3 6.000000 300.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 2.000000 150.0000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 3 6.000000 333.0000 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 1 2.000000 111.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 13 26.000000 1950.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 1 2.000000 150.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 16 32.000000 2400.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 4 8.000000 600.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 15 30.000000 2250.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 8 16.000000 1200.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 17 34.000000 1887.0000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 4 8.000000 444.0000 55.5000
OCTF-97168-OT RE-EVAL EST PLAN CARE 20 20.999999 1079.6100 51.4100
OCTH-97166-OT EVAL MODERATE COMPLEXITY 1 1.000000 51.4100 51.4100
OCTH-97167-OT EVAL HIGH COMPLEXITY 24 24.000000 1233.8400 51.4100
OCTH-97167GT-OT EVAL HIGH COMPLEXITY 1 1.000000 51.4100 51.4100
OCTH-97167TLGT-OT EVAL HIGH COMPLEXITY 1 2.000000 102.8200 51.4100
PSTF-97164-PT RE-EVAL EST PLAN CARE 6 6.000000 308.4600 51.4100
PSTH-97163-PT EVAL HIGH COMPLEXITY 6 6.000000 308.4600 51.4100
PSTH-97163GT-PT EVAL HIGH COMPLEXITY 1 1.000000 51.4100 51.4100
SPCH-92521-EVAL OF SPEECH FLUENCY 1 1.000000 51.4100 51.4100
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 15 15.000000 771.1500 51.4100
Subtotal (Total Children Is Unduplicated) 141 255.999999 16184.9800 63.2226
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 1 1.000000 20.0000 20.0000
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 7 8.000000 400.0000 50.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 26 23.000000 1150.0000 50.0000
CONIF-CONIFGT-CONSULT,ITDS,FACE TO FACE 9 11.500000 575.0000 50.0000
CONIP-CONIP-CONSULT, ITDS PHONE 26 33.500000 837.5000 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 9 15.500000 775.0000 50.0000
CONOP-CONOP-CONSULT, OT, PHONE 27 57.000000 1425.0000 25.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 1 2.000000 100.0000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 23 20.500000 1025.0000 50.0000
CONSF-CONSFGT-CONSULT,SLP,FACE TO FACE 8 9.500000 475.0000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 22 20.500000 512.5000 25.0000
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 1 2.000000 100.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 251 1711.500000 85575.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 18 97.500000 4875.0000 50.0000
INTR-T1013-INTERPRETER 1 2.500000 270.0000 108.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 543 4521.000000 45210.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 96 536.750001 38624.5300 71.9600
OCCT-97530GT-OT SESSION BY LICENSED OT 1 8.000000 575.6800 71.9600
OCCT-97530HM-OT SESSION BY OT ASST 129 994.015103 57255.2700 57.6000
OCCT-97530HMGT-OT SESSION BY OT ASST 1 4.000000 230.4000 57.6000
OCCT-97530TLHM-OT SESSION BY OT ASST 2 26.000000 1497.6000 57.6000
PHY-97110-PT SESSION BY LICENSED PT 60 446.499986 32130.1400 71.9600
PHY-97110GT-PT SESSION BY LICENSED PT 1 7.000000 503.7200 71.9600
PHY-97110HM-PT SESSION BY PT ASST 61 400.750000 23067.1700 57.5600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 148 814.999998 58647.4000 71.9600
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 1 7.000000 503.7200 71.9600
TRAV-TRAVS-Travel by mile 33 1397.000000 621.3200 0.4448
Subtotal (Total Children Is Unduplicated) 589 11178.51509 356981.9500 31.9346
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Total 11434.515087 373166.9300 32.6351
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Number of Children (Unduplicated) With at Least One Service 649
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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 5744 6790.953489 133096.3800 133096.3800
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
4517 4643.561598 240070.5500 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 10261 11434.515087 373166.9300 133096.3800