CMS/EIP Fiscal Report Center: 02
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 684 597.000000 22208.4000 37.2000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 141 160.500000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 164 323.750000 12043.5000 37.2000
Subtotal (Total Children Is Unduplicated) 708 1081.250000 34251.9000 31.6781
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Screening, Eval, and Assessment,Class #02
EXIT-EXIT-EXIT ASSESSMENT 6 6.000000 300.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 1.500000 112.5000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 1 2.000000 150.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 2 3.500000 194.2500 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 2 3.500000 194.2500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 7 12.000000 900.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 9 19.000000 1425.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 36 65.500000 3579.7500 54.6527
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 14 25.000000 1387.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 18 33.000000 2475.0000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 10 19.000000 1425.0000 75.0000
OCTH-97167-OT EVAL HIGH COMPLEXITY 1 1.000000 51.4100 51.4100
Subtotal (Total Children Is Unduplicated) 75 191.000000 12194.6600 63.8464
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 1 1.000000 49.9900 49.9900
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 13 16.500000 825.0000 50.0000
COIFF-COIFFGT-IFSP CONSULT,PROF,FACE TO FACE 11 15.000000 750.0000 50.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 58 57.250000 2862.5000 50.0000
CONIF-CONIFGT-CONSULT,ITDS,FACE TO FACE 15 12.000000 600.0000 50.0000
CONIP-CONIP-CONSULT, ITDS PHONE 1 0.750000 18.7500 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 17 16.500000 825.0000 50.0000
CONOF-CONOFGT-CONSULT,OT,FACE TO FACE 16 10.750000 537.5000 50.0000
CONOP-CONOP-CONSULT, OT, PHONE 2 1.000000 25.0000 25.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 3 3.000000 150.0000 50.0000
CONPF-CONPFGT-CONSULT,PT,FACE TO FACE 1 1.500000 75.0000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 19 15.000000 750.0000 50.0000
CONSF-CONSFGT-CONSULT,SLP,FACE TO FACE 17 13.250000 662.5000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 78 392.000000 19600.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 20 88.000000 4400.0000 50.0000
INTR-T1013-INTERPRETER 22 93.500000 4675.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 285 1698.000000 16980.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 2 5.000000 359.8000 71.9600
OCCT-97530GT-OT SESSION BY LICENSED OT 2 9.000000 647.6400 71.9600
PHY-97110-PT SESSION BY LICENSED PT 3 5.250000 188.5900 35.9219
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 2 11.000000 791.5600 71.9600
TELEC-TELEC-TELECONFERENCE,PROVIDER TO FAMILY,PHONE 3 2.750000 101.7500 37.0000
TRAV-TRAVS-Travel by mile 209 15733.00000 6999.6800 0.4449
Subtotal (Total Children Is Unduplicated) 418 18201.00000 62875.2600 3.4545
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Total 19473.250000 109321.8200 5.6139
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Number of Children (Unduplicated) With at Least One Service 845
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Center 02
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 2434 11494.750000 52838.3200 52810.9000
348 1343.750000 5471.9800 0.0000
Other 2643 6634.750000 51011.5200 0.0000
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Total 5425 19473.250000 109321.8200 52810.9000