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
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-T1024GNTS-F/U PSYCH 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 7 14.000000 1050.0000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 2 4.000000 300.0000 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 44 88.000000 6600.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 8 15.000000 1125.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 67 133.000000 9975.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 13 26.000000 1950.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 103 205.000000 15375.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 20 39.000000 2925.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 110 220.000000 12210.0000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 25 50.000000 2775.0000 55.5000
OCTF-97168-OT RE-EVAL EST PLAN CARE 35 46.000000 2362.3400 51.3552
OCTH-97165-OT EVAL LOW COMPLEXITY 2 4.000000 205.6400 51.4100
OCTH-97166-OT EVAL MODERATE COMPLEXITY 11 11.000000 564.7900 51.3445
OCTH-97166TLGT-OT EVAL MODERATE COMPLEXITY 1 1.000000 51.4100 51.4100
OCTH-97167-OT EVAL HIGH COMPLEXITY 57 65.000000 3338.0500 51.3546
OCTH-97167GT-OT EVAL HIGH COMPLEXITY 3 3.000000 153.8700 51.2900
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 10 14.000000 719.3800 51.3843
PSTH-97161-PT EVAL LOW COMPLEXITY 1 1.000000 51.4100 51.4100
PSTH-97163-PT EVAL HIGH COMPLEXITY 14 14.000000 718.6600 51.3329
PSTH-97163GT-PT EVAL HIGH COMPLEXITY 2 2.000000 102.4600 51.2300
SPCH-92521-EVAL OF SPEECH FLUENCY 1 1.000000 51.4100 51.4100
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 34 38.000000 1952.5000 51.3816
SPCH-92523GT-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 1 2.000000 102.8200 51.4100
Subtotal (Total Children Is Unduplicated) 486 1047.000000 67867.6100 64.8210
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 317 4973.500000 248675.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 29 325.250000 16262.5000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 108 1570.250000 112874.8100 71.8833
OCCT-97530GT-OT SESSION BY LICENSED OT 2 25.000000 1792.7600 71.7104
OCCT-97530HM-OT SESSION BY OT ASST 159 2872.500000 165244.6000 57.5264
OCCT-97530HMGT-OT SESSION BY OT ASST 4 33.000000 1894.4000 57.4061
OCCT-97530TLHM-OT SESSION BY OT ASST 2 62.000000 3568.8000 57.5613
PHY-97110-PT SESSION BY LICENSED PT 50 933.250000 67076.5900 71.8742
PHY-97110GT-PT SESSION BY LICENSED PT 2 16.000000 1147.7200 71.7325
PHY-97110HM-PT SESSION BY PT ASST 63 1481.250000 85170.9500 57.4994
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 209 2874.250000 206521.5000 71.8523
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 2 34.000000 2443.5200 71.8682
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 2 2.000000 143.9200 71.9600
Subtotal (Total Children Is Unduplicated) 714 15230.25000 914630.3500 60.0535
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Total 16277.250000 982497.9600 60.3602
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Number of Children (Unduplicated) With at Least One Service 886
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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 0 0.000000 0.0000 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
15918 16277.250000 982497.9600 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 15918 16277.250000 982497.9600 0.0000