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
Payclass Filters:GR
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 523 862.750000 32092.3500 37.1977
Subtotal (Total Children Is Unduplicated) 598 894.250000 33264.1500 37.1978
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Screening, Eval, and Assessment,Class #02
ASTE-ASTE-ASSISTIVE TECHNOLOGY EVAL 5 5.000000 242.5000 48.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 1 1.500000 112.5000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 2 5.000000 375.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 1 1.500000 112.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 5 8.500000 471.7500 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 3 5.500000 305.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 7 14.500000 1087.5000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 9 20.000000 1409.9300 70.4965
OCTH-97165-OT EVAL LOW COMPLEXITY 1 1.000000 51.4100 51.4100
Subtotal (Total Children Is Unduplicated) 28 62.500000 4168.3400 66.6934
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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-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 51 183.250000 9162.5000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 4 8.000000 400.0000 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 3 10.000000 719.6000 71.9600
PHY-97110-PT SESSION BY LICENSED PT 10 33.750000 2120.5700 62.8317
PHY-97110GT-PT SESSION BY LICENSED PT 1 1.000000 71.9600 71.9600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 9 30.750000 2212.7700 71.9600
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 2 2.000000 143.9200 71.9600
TRAV-TRAVS-Travel by mile 546 31268.00000 12938.8100 0.4138
Subtotal (Total Children Is Unduplicated) 1481 38276.50000 127858.8800 3.3404
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Total 39233.250000 165291.3700 4.2130
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Number of Children (Unduplicated) With at Least One Service 1783
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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 4579 23319.000000 60473.7900 60473.7900
D 514 3095.500000 6442.2900 0.0000
S 4 1.750000 65.1000 0.0000
H 0 0.000000 0.0000 0.0000
T 4270 11742.250000 56320.7400 56300.7400
1705 1074.750000 41989.4500 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 11072 39233.250000 165291.3700 116774.5300