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:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
CASE-CASE-NON-TCM CASE MANAGEMENT 2522 4642.750000 172469.4500 37.1481
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 337 372.750000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 2633 20176.25000 748068.0500 37.0767
Subtotal (Total Children Is Unduplicated) 2706 25191.75000 920537.5000 36.5412
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Screening, Eval, and Assessment,Class #02
EVAL-96111-DEVELOPMENTAL EVALUATION 98 242.000000 12100.0000 50.0000
EVAL-96111GT-DEVELOPMENTAL EVALUATION 22 47.000000 2350.0000 50.0000
EXIT-EXIT-EXIT ASSESSMENT 49 91.000000 4550.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 73 156.000000 11700.0000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 7 14.000000 1050.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 6 12.000000 900.0000 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 34 68.000000 5100.0000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 5 10.000000 750.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 2 4.000000 300.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 25 50.000000 2775.0000 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 1153 2318.379989 173878.5000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 162 326.999998 24525.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 175 348.999997 26175.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 38 76.000000 5700.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 277 552.999999 41475.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 53 105.000000 7875.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 656 1333.999998 74037.0000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 122 244.000000 13542.0000 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 79 90.069829 4626.8900 51.3700
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) 1740 6430.449806 430981.3400 67.0220
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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 1075 22617.00000 226100.0000 9.9969
OCCT-97530-OT SESSION BY LICENSED OT 199 2814.158698 202295.6100 71.8849
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:Program Patients
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) 1230 61950.56137 1927599.8600 31.1151
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Total 93572.761178 3279118.7000 35.0435
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Number of Children (Unduplicated) With at Least One Service 2726
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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 3824 3868.703067 177195.0800 0.0000
P 42519 50731.196741 1224442.3000 1223874.0900
D 1 0.250000 9.3000 0.0000
S 11 14.247200 992.5400 37.5000
H 184 300.165509 21928.5900 0.0000
T 0 0.000000 0.0000 0.0000
43805 38657.948661 1854541.5900 0.0000
Other 1 0.250000 9.3000 9.3000
---------------------------------------------------------
Total 90345 93572.761178 3279118.7000 1223920.8900