CMS/EIP Fiscal Report Center: 51
Services beginning 07/01/2022 ending 06/30/2023 Date of Report:07/25/2023 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-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 1.000000 75.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 1.000000 75.0000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 1 1.000000 75.0000 75.0000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 4 4.000000 300.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 2 2.000000 150.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 2 2.500000 187.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 1 1.000000 75.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 1 1.000000 75.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 5 5.000000 277.5000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 2 2.500000 138.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 20 20.000000 1500.0000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 17 19.000000 1425.0000 75.0000
OCTF-97168-OT RE-EVAL EST PLAN CARE 1 1.000000 51.4100 51.4100
OCTH-97165-OT EVAL LOW COMPLEXITY 15 15.000000 770.4300 51.3620
OCTH-97165GT-OT EVAL LOW COMPLEXITY 1 1.000000 51.4100 51.4100
OCTH-97165TL-OT EVAL LOW COMPLEXITY 4 4.000000 205.6400 51.4100
OCTH-97166-OT EVAL MODERATE COMPLEXITY 4 4.000000 205.6400 51.4100
OCTH-97166TL-OT EVAL MODERATE COMPLEXITY 1 1.000000 51.4100 51.4100
OCTH-97167-OT EVAL HIGH COMPLEXITY 6 8.000000 411.2800 51.4100
PSTH-97161-PT EVAL LOW COMPLEXITY 4 4.000000 205.6400 51.4100
PSTH-97162-PT EVAL MODERATE COMPLEXITY 1 1.000000 51.4100 51.4100
SPCH-92521-EVAL OF SPEECH FLUENCY 4 5.000000 257.0500 51.4100
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 3 3.000000 153.8700 51.2900
SPCH-92523GT-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 1 1.000000 51.4100 51.4100
Subtotal (Total Children Is Unduplicated) 87 108.000000 6820.3500 63.1514
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 149 2415.000000 120750.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 10 54.000000 2700.0000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 128 859.750000 61562.6800 71.6053
OCCT-97530GT-OT SESSION BY LICENSED OT 15 46.000000 3306.7800 71.8865
OCCT-97530HM-OT SESSION BY OT ASST 39 386.750000 22234.9000 57.4917
OCCT-97530HMGT-OT SESSION BY OT ASST 6 15.000000 864.0000 57.6000
OCCT-97530TL-OT SESSION BY LICENSED OT 2 3.750000 269.8500 71.9600
OCCT-97530TLGT-OT SESSION BY LICENSED OT 1 4.000000 285.7600 71.4400
OCCT-97530TLGTHM-OT SESSION BY OT ASST 5 10.250000 587.1000 57.2780
OCCT-97530TLHM-OT SESSION BY OT ASST 1 1.000000 57.6000 57.6000
PHY-97110-PT SESSION BY LICENSED PT 29 404.500000 29055.1700 71.8298
PHY-97110GT-PT SESSION BY LICENSED PT 2 7.000000 503.7200 71.9600
PHY-97110TL-PT SESSION BY LICENSED PT 2 39.750000 2859.2400 71.9306
PHY-97110TLGT-PT SESSION BY LICENSED PT 1 1.000000 71.4400 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 101 1463.750000 104599.7900 71.4601
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 8 76.000000 5461.1600 71.8574
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 1 2.000000 143.9200 71.9600
Subtotal (Total Children Is Unduplicated) 341 5789.500000 355313.1100 61.3720
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Total 5897.500000 362133.4600 61.4046
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Number of Children (Unduplicated) With at Least One Service 363
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Center 51
Flag Claims Units Chgs Paid
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R 2 2.500000 138.7500 0.0000
U 0 0.000000 0.0000 0.0000
B 0 0.000000 0.0000 0.0000
P 1 4.000000 200.0000 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
1919 5891.000000 361794.7100 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 1922 5897.500000 362133.4600 0.0000