CMS/EIP Fiscal Report Center: 01
Services beginning 10/01/2022 ending 12/31/2022 Date of Report:01/23/2023 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 96 31.500000 1171.8000 37.2000
TCM-T1017TL-TARGETED CASE MANAGEMENT 1701 2805.500000 104358.9000 37.1980
Subtotal (Total Children Is Unduplicated) 1724 2837.000000 105530.7000 37.1980
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Screening, Eval, and Assessment,Class #02
ASTE-ASTE-ASSISTIVE TECHNOLOGY EVAL 5 5.000000 242.5000 48.5000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 1.500000 112.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 1.500000 112.5000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 3 9.500000 712.5000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 2 5.500000 412.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 3 4.500000 249.7500 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 2 3.500000 91.5000 26.1429
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 20 32.500000 2437.5000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 23 38.000000 2850.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 11 18.500000 1387.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 3 4.500000 337.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 23 39.000000 2925.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 6 10.000000 750.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 59 97.000000 5383.5000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 77 124.500000 6909.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 86 191.500000 14362.5000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 91 183.500000 13672.4300 74.5092
OCTH-97165-OT EVAL LOW COMPLEXITY 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
SPCH-92521-EVAL OF SPEECH FLUENCY 4 4.000000 205.6400 51.4100
SPCH-92523GT-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 1 1.000000 51.4100 51.4100
SPCH-92610-EVAL OF ORAL,PHARYNGEAL SWALLOWING FUNC 1 1.000000 44.8600 44.8600
SPL-92526-TREATMENT OF SWALLOWING DYSFUNCTION 2 6.000000 317.5800 52.9300
SPL-92526TL-TREATMENT OF SWALLOWING DYSFUNCTION 1 4.000000 211.7200 52.9300
Subtotal (Total Children Is Unduplicated) 264 789.000000 53934.8700 68.3585
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 68 81.000000 4050.0000 50.0000
COIFF-COIFFGT-IFSP CONSULT,PROF,FACE TO FACE 66 86.000000 4287.5000 49.8547
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 23 22.250000 556.2500 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 30 34.000000 1700.0000 50.0000
CONIF-CONIFGT-CONSULT,ITDS,FACE TO FACE 66 88.500000 4425.0000 50.0000
CONIP-CONIP-CONSULT, ITDS PHONE 5 5.000000 125.0000 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 24 31.000000 1550.0000 50.0000
CONOF-CONOFGT-CONSULT,OT,FACE TO FACE 25 34.000000 1700.0000 50.0000
CONOP-CONOP-CONSULT, OT, PHONE 3 3.000000 75.0000 25.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 28 33.250000 1662.5000 50.0000
CONPF-CONPFGT-CONSULT,PT,FACE TO FACE 18 23.000000 1150.0000 50.0000
CONPP-CONPP-CONSULT, PT, PHONE 4 3.250000 81.2500 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 37 44.000000 2200.0000 50.0000
CONSF-CONSFGT-CONSULT,SLP,FACE TO FACE 54 78.250000 3912.5000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 6 4.750000 118.7500 25.0000
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 7 6.250000 312.5000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 414 1458.000000 72900.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 39 71.500000 3575.0000 50.0000
INTR-T1013-INTERPRETER 103 272.500000 13625.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 1301 5896.000000 58870.0000 9.9847
OCCT-97530-OT SESSION BY LICENSED OT 26 78.000000 5612.8800 71.9600
OCCT-97530GT-OT SESSION BY LICENSED OT 5 8.250000 593.6700 71.9600
OCCT-97530TL-OT SESSION BY LICENSED OT 8 18.000000 1295.2800 71.9600
PHY-97110-PT SESSION BY LICENSED PT 40 146.500000 10234.0600 69.8571
PHY-97110GT-PT SESSION BY LICENSED PT 5 5.000000 359.8000 71.9600
PHY-97110TL-PT SESSION BY LICENSED PT 19 51.000000 3669.9600 71.9600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 79 313.250000 22398.5900 71.5039
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 17 67.250000 4839.3100 71.9600
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 7 12.750000 917.4900 71.9600
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 4 9.000000 647.6400 71.9600
TRAV-TRAVS-Travel by mile 546 31268.00000 12938.8100 0.4138
Subtotal (Total Children Is Unduplicated) 1565 40252.50000 240383.7400 5.9719
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Total 43878.500000 399849.3100 9.1126
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Number of Children (Unduplicated) With at Least One Service 2398
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Center 01
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 5277 24026.000000 102143.9800 102143.9800
D 609 3194.500000 11840.6800 0.0000
S 3587 2422.500000 104456.6200 0.0000
H 165 198.000000 13446.7700 0.0000
T 5191 12671.750000 106278.4300 106124.8500
1782 1166.500000 48181.3300 0.0000
Other 142 199.250000 13501.5000 0.0000
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Total 16753 43878.500000 399849.3100 208268.8300