CMS/EIP Fiscal Report Center: 55
Services beginning 01/01/2023 ending 03/31/2023 Date of Report:04/20/2023 Page: 1
List order: No List
Agency Filter:EXT
Payclass Filters:MED
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
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 2.000000 150.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 3 6.000000 450.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 2.000000 150.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 2.000000 111.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 6 12.000000 900.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 9 18.000000 1350.0000 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 24 48.000000 3600.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 29 58.000000 3219.0000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 1 2.000000 111.0000 55.5000
OCTF-97168-OT RE-EVAL EST PLAN CARE 10 10.000000 514.1000 51.4100
OCTH-97165-OT EVAL LOW COMPLEXITY 1 3.000000 154.2300 51.4100
OCTH-97166-OT EVAL MODERATE COMPLEXITY 2 2.000000 102.8200 51.4100
OCTH-97166TLGT-OT EVAL MODERATE COMPLEXITY 1 1.000000 51.4100 51.4100
OCTH-97167-OT EVAL HIGH COMPLEXITY 14 17.000000 873.9700 51.4100
PSTF-97164-PT RE-EVAL EST PLAN CARE 3 6.000000 308.4600 51.4100
PSTH-97163-PT EVAL HIGH COMPLEXITY 4 4.000000 205.6400 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 10 10.000000 514.1000 51.4100
Subtotal (Total Children Is Unduplicated) 117 216.000000 13717.1400 63.5053
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 156 1063.250000 53162.5000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 11 63.500000 3175.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 59 269.000000 19357.2400 71.9600
OCCT-97530GT-OT SESSION BY LICENSED OT 1 2.000000 143.9200 71.9600
OCCT-97530HM-OT SESSION BY OT ASST 73 549.250000 31636.8000 57.6000
OCCT-97530HMGT-OT SESSION BY OT ASST 1 6.000000 345.6000 57.6000
OCCT-97530TLHM-OT SESSION BY OT ASST 1 18.000000 1036.8000 57.6000
PHY-97110-PT SESSION BY LICENSED PT 27 170.000000 12233.2000 71.9600
PHY-97110GT-PT SESSION BY LICENSED PT 1 2.000000 143.9200 71.9600
PHY-97110HM-PT SESSION BY PT ASST 40 239.750000 13800.0100 57.5600
PHY-97110HMGT-PT SESSION BY LICENSED PT ASST 1 6.000000 345.3600 57.5600
PHY-97110TL-PT SESSION BY LICENSED PT 1 7.000000 503.7200 71.9600
PHY-97110TLHM-PT SESSION BY PT ASST 1 7.000000 402.9200 57.5600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 86 503.000000 36195.8800 71.9600
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 1 9.000000 647.6400 71.9600
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 1 1.000000 71.9600 71.9600
Subtotal (Total Children Is Unduplicated) 368 2915.750000 173202.4700 59.4024
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Total 3131.750000 186919.6100 59.6854
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Number of Children (Unduplicated) With at Least One Service 422
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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 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 0 0.000000 0.0000 0.0000
3067 3131.750000 186919.6100 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 3067 3131.750000 186919.6100 0.0000