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
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
EVAL-96111-DEVELOPMENTAL EVALUATION 17 35.000000 1750.0000 50.0000
EXIT-EXIT-EXIT ASSESSMENT 12 24.000000 1200.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 9 18.000000 1350.0000 75.0000
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 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 2 4.000000 222.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 77 154.000000 11550.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 9 17.000000 1275.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 121 240.999999 18075.0000 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 149 300.000000 16650.0000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 36 72.000000 3996.0000 55.5000
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 2 2.000000 102.8200 51.4100
SPCH-92521GT-EVAL OF SPEECH FLUENCY 1 1.000000 51.4100 51.4100
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 61 68.069829 3497.3100 51.3783
SPCH-92523GT-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 2 3.000000 154.2300 51.4100
Subtotal (Total Children Is Unduplicated) 799 1779.069824 115025.8900 64.6551
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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 31 40.250000 2012.5000 50.0000
COIFF-COIFFGT-IFSP CONSULT, PROF, TELEMEDICINE 2 3.000000 150.0000 50.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 99 173.750000 8687.5000 50.0000
CONIF-CONIFGT-CONSULT, ITDS, TELEMEDICINE 20 40.000000 2000.0000 50.0000
CONIP-CONIP-CONSULT, ITDS PHONE 81 202.250000 5056.2500 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 85 154.750000 7737.5000 50.0000
CONSF-CONSFGT-CONSULT, SLP, TELEMEDICINE 20 38.000000 1900.0000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 74 159.250000 3981.2500 25.0000
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 1 2.000000 100.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 478 7470.500000 373525.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 40 428.250000 21412.5000 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
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 345 4767.289727 342563.6600 71.8571
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 3 36.000000 2587.4400 71.8733
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 2 2.000000 143.9200 71.9600
TRAV-TRAVS-Travel by mile 113 10964.00000 4876.8200 0.4448
Subtotal (Total Children Is Unduplicated) 1140 59973.89587 1816752.5100 30.2924
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Total 61752.965692 1931778.4000 31.2824
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Number of Children (Unduplicated) With at Least One Service 1378
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Center 55
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 32084 40217.693142 768093.2800 768078.2800
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 1 2.000000 150.0000 0.0000
T 0 0.000000 0.0000 0.0000
19908 21533.272550 1163535.1200 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 51993 61752.965692 1931778.4000 768078.2800