CMS/EIP Fiscal Report Center: 09
Services beginning 04/01/2023 ending 06/30/2023 Date of Report:07/25/2023 Page: 1
List order: No List
Agency Filter:EXT
Payclass Filters:GR
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
EXIT-EXIT-EXIT ASSESSMENT 5 10.000000 500.0000 50.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 2 4.000000 300.0000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 1 2.000000 150.0000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 2 4.000000 300.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 38 76.000000 5700.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 27 53.000000 3975.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 27 52.000000 3900.0000 75.0000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 16 32.000000 1776.0000 55.5000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 13 25.000000 1875.0000 75.0000
NUTR-97802-NUTRITIONAL EVAL, INITIAL 4 11.000000 550.0000 50.0000
NUTR-97803-NUTRITIONAL EVAL, FOLLOW-UP 17 55.000000 2750.0000 50.0000
SPL-92526-TREATMENT OF SWALLOWING DYSFUNCTION 1 3.000000 158.7900 52.9300
Subtotal (Total Children Is Unduplicated) 121 329.000000 22084.7900 67.1270
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 63 107.500000 5325.0000 49.5349
COIFF-COIFFGT-IFSP CONSULT, PROF, TELEMEDICINE 8 13.000000 650.0000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 69 80.500000 2012.5000 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 9 9.000000 450.0000 50.0000
CONIF-CONIFGT-CONSULT, ITDS, TELEMEDICINE 2 2.000000 100.0000 50.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 12 12.000000 600.0000 50.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 6 7.500000 375.0000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 8 7.750000 387.5000 50.0000
CONSF-CONSFGT-CONSULT, SLP, TELEMEDICINE 4 3.000000 150.0000 50.0000
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 5 17.000000 850.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 368 1702.000000 85000.0000 49.9412
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 10 18.000000 900.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 357 1519.000000 15140.0000 9.9671
OCCT-97530-OT SESSION BY LICENSED OT 38 150.000000 10794.0000 71.9600
PHY-97110-PT SESSION BY LICENSED PT 26 132.750000 9552.6900 71.9600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 65 292.500000 21048.3000 71.9600
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 1 4.000000 287.8400 71.9600
TRAV-TRAVS-Travel by mile 1239 92551.00000 40605.2700 0.4387
Subtotal (Total Children Is Unduplicated) 1304 96628.50000 194228.1000 2.0101
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Total 96957.500000 216312.8900 2.2310
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Number of Children (Unduplicated) With at Least One Service 1367
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Center 09
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 3600 92648.500000 200861.7300 200861.7300
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 218 4271.000000 12601.1600 12601.1600
0 0.000000 0.0000 0.0000
Other 19 38.000000 2850.0000 0.0000
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Total 3837 96957.500000 216312.8900 213462.8900