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
Payclass Filters:GR
Eligibility Filter:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Screening, Eval, and Assessment,Class #02
EVAL-96111GT-DEVELOPMENTAL EVALUATION 7 7.000000 350.0000 50.0000
EXIT-EXIT-EXIT ASSESSMENT 1 1.000000 50.0000 50.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 24 24.000000 1800.0000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 1 1.000000 75.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 76 76.500000 4245.7500 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 1 1.000000 55.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 10 10.000000 750.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 8 8.000000 600.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 1 1.000000 75.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 2 2.000000 96.7900 48.3950
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 3 4.000000 300.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 50 57.000000 3163.5000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 9 15.000000 832.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 134 135.500000 10162.5000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 11 11.500000 862.5000 75.0000
OCTH-97165-OT EVAL LOW COMPLEXITY 25 27.000000 1348.5400 49.9459
OCTH-97165GT-OT EVAL LOW COMPLEXITY 1 1.000000 51.4100 51.4100
OCTH-97166-OT EVAL MODERATE COMPLEXITY 12 12.000000 616.9200 51.4100
OCTH-97166GT-OT EVAL MODERATE COMPLEXITY 2 2.000000 102.8200 51.4100
OCTH-97167-OT EVAL HIGH COMPLEXITY 12 12.000000 616.5600 51.3800
OCTH-97167GT-OT EVAL HIGH COMPLEXITY 1 1.000000 51.0500 51.0500
PSTH-97161-PT EVAL LOW COMPLEXITY 8 9.000000 462.6900 51.4100
PSTH-97162-PT EVAL MODERATE COMPLEXITY 5 5.000000 257.0500 51.4100
PSTH-97163-PT EVAL HIGH COMPLEXITY 1 1.000000 51.4100 51.4100
SPCH-92521-EVAL OF SPEECH FLUENCY 25 31.000000 1432.5700 46.2119
SPCH-92522GT-EVAL OF SPCH SOUND PROD 1 1.000000 51.4100 51.4100
Subtotal (Total Children Is Unduplicated) 268 456.500000 28461.4700 62.3471
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 2 5.000000 391.5000 78.3000
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 19 22.500000 1087.5000 48.3333
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 1 1.000000 50.0000 50.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 1 3.000000 150.0000 50.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 2 2.000000 100.0000 50.0000
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 15 75.000000 3630.0000 48.4000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 58 807.750000 39677.5000 49.1210
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 5 42.000000 2100.0000 50.0000
INTR-T1013-INTERPRETER 2 10.500000 315.0000 30.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 844 16423.00000 165670.0000 10.0877
OCCT-97530-OT SESSION BY LICENSED OT 105 997.750000 67075.9000 67.2272
OCCT-97530GT-OT SESSION BY LICENSED OT 20 130.500000 7736.8600 59.2863
OCCT-97530HM-OT SESSION BY OT ASST 55 541.500000 30952.2300 57.1602
OCCT-97530HMGT-OT SESSION BY OT ASST 5 17.000000 979.2000 57.6000
PHY-97110-PT SESSION BY LICENSED PT 44 558.750000 38841.6400 69.5152
PHY-97110GT-PT SESSION BY LICENSED PT 1 8.000000 574.1200 71.7650
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 165 2423.000000 168298.0800 69.4586
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 16 80.000000 5519.8100 68.9976
Subtotal (Total Children Is Unduplicated) 862 22148.25000 533149.3400 24.0718
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Total 22604.750000 561610.8100 24.8448
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Number of Children (Unduplicated) With at Least One Service 915
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Center 51
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 7512 22518.250000 557532.4900 557532.4900
D 1 4.000000 251.8600 251.8600
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
44 82.500000 3826.4600 100.0000
Other 0 0.000000 0.0000 0.0000
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Total 7557 22604.750000 561610.8100 557884.3500