CMS/EIP Fiscal Report Center: 03
Services beginning 10/01/2022 ending 12/31/2022 Date of Report:01/23/2023 Page: 1
List order: No List
Eligibility Filter:Part C (excluding not eligible)
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
CASE-CASE-NON-TCM CASE MANAGEMENT 446 317.250000 11801.7000 37.2000
TCM-T1017TL-TARGETED CASE MANAGEMENT 1100 2570.250000 95607.0000 37.1975
Subtotal (Total Children Is Unduplicated) 1161 2887.500000 107408.7000 37.1978
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 2 3.000000 225.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 4 8.000000 600.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 4 6.000000 450.0000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 1 1.000000 75.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 4 8.000000 444.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 17 30.500000 2287.5000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 1 2.000000 150.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 32 58.000000 4350.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 11 21.500000 1612.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 2 2.500000 145.5000 58.2000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 98 186.000000 10323.0000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 3 5.000000 277.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 23 42.000000 3150.0000 75.0000
OCTH-97167-OT EVAL HIGH COMPLEXITY 2 2.000000 102.8200 51.4100
PSTF-97164-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 2 2.000000 102.8200 51.4100
SCREEN-T1023-SCREENING 29 29.000000 1450.0000 50.0000
SPL-92526-TREATMENT OF SWALLOWING DYSFUNCTION 2 3.000000 158.7900 52.9300
Subtotal (Total Children Is Unduplicated) 198 411.500000 26007.2500 63.2011
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 72 77.250000 3862.5000 50.0000
COIFF-COIFFGT-IFSP CONSULT,PROF,FACE TO FACE 66 58.000000 2900.0000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 1 1.000000 25.0000 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 9 11.500000 575.0000 50.0000
CONIF-CONIFGT-CONSULT,ITDS,FACE TO FACE 5 7.250000 362.5000 50.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 16 20.000000 1000.0000 50.0000
CONOF-CONOFGT-CONSULT,OT,FACE TO FACE 5 5.000000 250.0000 50.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 19 25.750000 1287.5000 50.0000
CONPF-CONPFGT-CONSULT,PT,FACE TO FACE 5 4.750000 237.5000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 34 38.000000 1900.0000 50.0000
CONSF-CONSFGT-CONSULT,SLP,FACE TO FACE 12 12.250000 612.5000 50.0000
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 23 61.500000 0.0000 0.0000
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 13 16.000000 800.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 140 448.500000 22425.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 55 107.500000 5375.0000 50.0000
INTR-T1013-INTERPRETER 5 13.750000 645.0000 46.9091
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 433 1343.000000 13430.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 10 27.000000 1905.5600 70.5763
PHY-97110-PT SESSION BY LICENSED PT 14 40.250000 2822.1900 70.1165
PHY-97110GT-PT SESSION BY LICENSED PT 3 7.500000 539.7000 71.9600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 19 56.750000 3717.1500 65.5004
TRAV-TRAVS-Travel by mile 413 24773.00000 11021.3400 0.4449
Subtotal (Total Children Is Unduplicated) 552 27155.50000 75693.4400 2.7874
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Total 30454.500000 209109.3900 6.8663
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Number of Children (Unduplicated) With at Least One Service 1322
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Center 03
Flag Claims Units Chgs Paid
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R 46 27.500000 1023.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 2064 1444.250000 55638.8500 0.0000
P 2525 18452.750000 58804.6900 58804.6900
D 3 4.250000 214.8000 0.0000
S 0 0.000000 0.0000 0.0000
H 74 471.000000 1684.3200 1684.3200
T 0 0.000000 0.0000 0.0000
3618 9914.500000 86247.7800 0.0000
Other 134 140.250000 5495.9500 0.0000
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Total 8464 30454.500000 209109.3900 60489.0100