CMS/EIP Fiscal Report Center: 55
Services beginning 07/01/2022 ending 06/30/2023 Date of Report:07/25/2023 Page: 1
List order: No List
Eligibility Filter:Part C (excluding not eligible)
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
CASE-CASE-NON-TCM CASE MANAGEMENT 1979 3876.250000 143994.1500 37.1478
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 309 344.250000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 2018 17067.75000 632674.1000 37.0684
Subtotal (Total Children Is Unduplicated) 2087 21288.25000 776668.2500 36.4834
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Screening, Eval, and Assessment,Class #02
EVAL-96111-DEVELOPMENTAL EVALUATION 79 170.000000 8500.0000 50.0000
EVAL-96111GT-DEVELOPMENTAL EVALUATION 20 41.000000 2050.0000 50.0000
EXIT-EXIT-EXIT ASSESSMENT 48 89.000000 4450.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 35 74.000000 5550.0000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 5 10.000000 750.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 3 6.000000 450.0000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 17 34.000000 2550.0000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC 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 12 24.000000 1332.0000 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 3 6.000000 333.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 702 1411.379992 105853.5000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 100 198.999998 14925.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 123 244.999998 18375.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 25 50.000000 3750.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 173 345.000000 25875.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 29 57.000000 4275.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 398 817.999998 45399.0000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 80 160.000000 8880.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 1 2.000000 150.0000 75.0000
OCTF-97168-OT RE-EVAL EST PLAN CARE 61 78.999999 4056.3500 51.3462
OCTH-97165-OT EVAL LOW COMPLEXITY 3 4.999999 256.6900 51.3380
OCTH-97166-OT EVAL MODERATE COMPLEXITY 15 17.000000 872.5300 51.3253
OCTH-97166GT-OT EVAL MODERATE COMPLEXITY 1 1.000000 51.4100 51.4100
OCTH-97166TLGT-OT EVAL MODERATE COMPLEXITY 1 1.000000 51.4100 51.4100
OCTH-97167-OT EVAL HIGH COMPLEXITY 112 128.999999 6625.4100 51.3598
OCTH-97167GT-OT EVAL HIGH COMPLEXITY 5 5.000000 256.3300 51.2660
OCTH-97167TL-OT EVAL HIGH COMPLEXITY 1 1.000000 51.0500 51.0500
OCTH-97167TLGT-OT EVAL HIGH COMPLEXITY 1 2.000000 102.8200 51.4100
PSTF-97164-PT RE-EVAL EST PLAN CARE 25 32.999999 1694.3700 51.3445
PSTF-97164GT-PT RE-EVAL EST PLAN CARE 1 1.000000 51.4100 51.4100
PSTH-97161-PT EVAL LOW COMPLEXITY 1 1.000000 51.4100 51.4100
PSTH-97162-PT EVAL MODERATE COMPLEXITY 1 1.000000 51.4100 51.4100
PSTH-97163-PT EVAL HIGH COMPLEXITY 33 34.000000 1745.0600 51.3253
PSTH-97163GT-PT EVAL HIGH COMPLEXITY 2 2.000000 102.4600 51.2300
SPCH-92521-EVAL OF SPEECH FLUENCY 4 4.000000 205.6400 51.4100
SPCH-92521GT-EVAL OF SPEECH FLUENCY 1 1.000000 51.4100 51.4100
SPCH-92521TL-EVAL OF SPEECH FLUENCY 2 3.000000 154.2300 51.4100
SPCH-92521TLGT-EVAL OF SPEECH FLUENCY 1 1.000000 51.4100 51.4100
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 78 89.069829 4575.4800 51.3696
SPCH-92523GT-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 2 3.000000 154.2300 51.4100
SPCH-92523TL-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 4 5.000000 257.0500 51.4100
SPCH-92610-EVAL OF ORAL,PHARYNGEAL SWALLOWING FUNC 1 1.000000 44.8600 44.8600
Subtotal (Total Children Is Unduplicated) 1166 4170.449811 275711.9300 66.1108
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 8 11.000000 11349.0000 1031.7273
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 36 45.750000 2287.5000 50.0000
COIFF-COIFFGT-IFSP CONSULT, PROF, TELEMEDICINE 2 3.000000 150.0000 50.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 159 256.750000 12837.5000 50.0000
CONIF-CONIFGT-CONSULT, ITDS, TELEMEDICINE 20 40.000000 2000.0000 50.0000
CONIP-CONIP-CONSULT, ITDS PHONE 88 211.250000 5281.2500 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 47 131.500000 6575.0000 50.0000
CONOP-CONOP-CONSULT, OT, PHONE 58 311.000000 7775.0000 25.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 4 7.000000 350.0000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 152 241.750000 12087.5000 50.0000
CONSF-CONSFGT-CONSULT, SLP, TELEMEDICINE 20 38.000000 1900.0000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 82 170.250000 4256.2500 25.0000
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 3 42.000000 2100.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 548 8553.000000 427650.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 52 486.250000 24312.5000 50.0000
INTR-T1013-INTERPRETER 2 4.500000 570.0000 126.6667
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 1073 22607.00000 226000.0000 9.9969
OCCT-97530-OT SESSION BY LICENSED OT 198 2805.158698 201647.9700 71.8847
OCCT-97530GT-OT SESSION BY LICENSED OT 3 29.000000 2080.6000 71.7448
OCCT-97530HM-OT SESSION BY OT ASST 247 5020.112450 288806.0600 57.5298
OCCT-97530HMGT-OT SESSION BY OT ASST 7 45.750000 2628.4000 57.4514
OCCT-97530TLHM-OT SESSION BY OT ASST 2 62.000000 3568.8000 57.5613
PHY-97110-PT SESSION BY LICENSED PT 107 2215.499969 159226.1400 71.8692
PHY-97110GT-PT SESSION BY LICENSED PT 4 19.000000 1363.6000 71.7684
PHY-97110HM-PT SESSION BY PT ASST 102 2196.085024 126264.3200 57.4952
PHY-97110HMGT-PT SESSION BY LICENSED PT ASST 1 7.000000 402.9200 57.5600
CMS/EIP Fiscal Report Center: 55
Services beginning 07/01/2022 ending 06/30/2023 Date of Report:07/25/2023 Page: 2
List order: No List
Eligibility Filter:Part C (excluding not eligible)
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
PHY-97110TL-PT SESSION BY LICENSED PT 1 14.000000 1007.4400 71.9600
PHY-97110TLHM-PT SESSION BY PT ASST 1 7.000000 402.9200 57.5600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 372 5084.205231 365337.7000 71.8574
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 6 41.500000 2982.8300 71.8754
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 20 255.000000 18324.8400 71.8621
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 2 6.250000 449.3600 71.8976
TRAV-TRAVS-Travel by mile 113 10964.00000 4876.8200 0.4448
Subtotal (Total Children Is Unduplicated) 1228 61931.56137 1926852.2200 31.1126
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Total 87390.261183 2979232.4000 34.0911
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Number of Children (Unduplicated) With at Least One Service 2107
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Center 55
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 3497 3293.750000 148008.8000 0.0000
P 41458 48901.109808 1126891.2300 1126526.0200
D 1 0.250000 9.3000 0.0000
S 10 12.913867 892.5400 37.5000
H 142 216.165509 15678.5900 0.0000
T 0 0.000000 0.0000 0.0000
39843 34965.821999 1687742.6400 0.0000
Other 1 0.250000 9.3000 9.3000
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Total 84952 87390.261183 2979232.4000 1126572.8200