CMS/EIP Fiscal Report Center: 57
Services beginning 07/01/2022 ending 06/30/2023 Date of Report:07/25/2023 Page: 1
List order: No List
Payclass Filters:OTHER
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-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 1 2.000000 150.0000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 1 2.000000 150.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 2 2.500000 187.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 1 1.500000 112.5000 75.0000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 5 9.000000 499.5000 55.5000
OCTF-97168-OT RE-EVAL EST PLAN CARE 2 2.000000 102.8200 51.4100
OCTH-97165-OT EVAL LOW COMPLEXITY 2 1.595604 82.0300 51.4100
OCTH-97167-OT EVAL HIGH COMPLEXITY 3 2.610971 133.5100 51.1342
PSTH-97161-PT EVAL LOW COMPLEXITY 1 1.000000 51.4100 51.4100
PSTH-97163-PT EVAL HIGH COMPLEXITY 3 3.000000 153.5100 51.1700
SPCH-92521-EVAL OF SPEECH FLUENCY 6 6.000000 307.7400 51.2900
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 2 2.000000 102.8200 51.4100
Subtotal (Total Children Is Unduplicated) 26 35.206575 2033.3400 57.7546
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EI Services,Class #03
CONOF-CONOF-CONSULT, OT, FACE TO FACE 2 2.000000 100.0000 50.0000
CONOF-CONOFGT-CONSULT, OT, TELEMEDICINE 6 6.000000 300.0000 50.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 1 1.000000 50.0000 50.0000
CONPF-CONPFGT-CONSULT, PT, TELEMEDICINE 1 1.000000 50.0000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 1 1.000000 50.0000 50.0000
CONSF-CONSFGT-CONSULT, SLP, TELEMEDICINE 3 2.500000 125.0000 50.0000
EIGF-T1027TTSC-EI GROUP SESSION BY EI PROF 10 97.000000 2425.0000 25.0000
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 1 1.000000 50.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 30 171.000000 8550.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 3 41.000000 2050.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 113 307.000000 3070.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 15 26.249308 1460.7800 55.6502
OCCT-97530HM-OT SESSION BY OT ASST 7 26.314238 1515.7000 57.6000
PHY-97110-PT SESSION BY LICENSED PT 2 4.000000 287.8400 71.9600
PHY-97110GT-PT SESSION BY LICENSED PT 2 4.000000 286.2800 71.5700
PHY-97110HM-PT SESSION BY PT ASST 1 1.000000 57.5600 57.5600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 21 64.005838 4614.8300 72.1001
SPL-92507HM-SPL THERAPY SESSION BY SLP ASST 4 11.168057 643.2800 57.6000
Subtotal (Total Children Is Unduplicated) 171 767.237441 25686.2700 33.4789
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Total 802.444016 27719.6100 34.5440
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Number of Children (Unduplicated) With at Least One Service 182
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Center 57
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 2 2.188160 157.4600 157.4600
D 0 0.000000 0.0000 0.0000
S 10 21.479167 632.8900 632.8900
H 0 0.000000 0.0000 0.0000
T 6 -5.000000 -477.6000 -477.6000
95 343.000000 15467.9600 14480.9600
Other 261 440.776689 11938.9000 11938.9000
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Total 374 802.444016 27719.6100 26732.6100