CMS/EIP Fiscal Report Center: 02
Services beginning 04/01/2023 ending 06/30/2023 Date of Report:07/25/2023 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
EXIT-EXIT-EXIT ASSESSMENT 16 19.000000 950.0000 50.0000
IPDEF-T1024GNTSGT-F/U PHYC 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
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 11 22.000000 1650.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 2 4.000000 300.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 2 4.000000 300.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 4 8.000000 444.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 5 9.500000 712.5000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 2 4.000000 300.0000 75.0000
OCTF-97168-OT RE-EVAL EST PLAN CARE 1 1.000000 37.1500 37.1500
OCTH-97165-OT EVAL LOW COMPLEXITY 1 1.000000 51.4100 51.4100
OCTH-97166GT-OT EVAL MODERATE COMPLEXITY 4 4.000000 205.6400 51.4100
PSTF-97164-PT RE-EVAL EST PLAN CARE 2 2.000000 74.3800 37.1900
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
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 4 4.000000 205.6400 51.4100
SPL-92526-TREATMENT OF SWALLOWING DYSFUNCTION 1 5.000000 219.6900 43.9380
Subtotal (Total Children Is Unduplicated) 53 95.500000 5956.0500 62.3670
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 2 4.000000 5515.6000 1378.9000
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 24 30.250000 1512.5000 50.0000
COIFF-COIFFGT-IFSP CONSULT, PROF, TELEMEDICINE 7 12.500000 625.0000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 2 1.750000 43.7500 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 79 104.000000 5200.0000 50.0000
CONIF-CONIFGT-CONSULT, ITDS, TELEMEDICINE 43 33.250000 1662.5000 50.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 17 16.500000 825.0000 50.0000
CONOF-CONOFGT-CONSULT, OT, TELEMEDICINE 40 36.000000 1800.0000 50.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 1 1.000000 50.0000 50.0000
CONPF-CONPFGT-CONSULT, PT, TELEMEDICINE 3 1.500000 75.0000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 24 23.000000 1150.0000 50.0000
CONSF-CONSFGT-CONSULT, SLP, TELEMEDICINE 12 9.250000 462.5000 50.0000
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 4 7.000000 350.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 83 634.750000 31737.5000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 23 76.750000 3837.5000 50.0000
INTR-T1013-INTERPRETER 13 65.750000 3287.5000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 350 2498.000000 25104.0000 10.0496
OCCT-97530-OT SESSION BY LICENSED OT 29 157.500000 10428.0800 66.2100
OCCT-97530GT-OT SESSION BY LICENSED OT 5 29.250000 2104.8300 71.9600
PHY-97110-PT SESSION BY LICENSED PT 25 135.750000 8859.4800 65.2632
PHY-97110GT-PT SESSION BY LICENSED PT 1 2.250000 161.9100 71.9600
SENS-V5264-EARMOLD 1 1.000000 18.1300 18.1300
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 40 210.000000 14857.4200 70.7496
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 1 1.000000 71.9600 71.9600
TRAV-TRAVS-Travel by mile 136 9882.000000 4396.2900 0.4449
Subtotal (Total Children Is Unduplicated) 423 13974.00000 124136.4500 8.8834
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Total 14069.500000 130092.5000 9.2464
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Number of Children (Unduplicated) With at Least One Service 432
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Center 02
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 3 3.000000 99.4600 -116.4200
H 0 0.000000 0.0000 0.0000
T 3686 11102.250000 101892.5800 102636.3470
1135 2964.250000 28100.4600 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 4824 14069.500000 130092.5000 102519.9270