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
Agency Filter:EXT
Payclass Filters:GR
Eligibility Filter:Part C (excluding not eligible)
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 1 2.500000 93.0000 37.2000
Subtotal (Total Children Is Unduplicated) 1 2.500000 93.0000 37.2000
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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
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 16 29.500000 2212.5000 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 29 53.000000 3975.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 10 19.500000 1462.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 20 37.500000 2081.2500 55.5000
OCTH-97167-OT EVAL HIGH COMPLEXITY 2 2.000000 102.8200 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
SPL-92526-TREATMENT OF SWALLOWING DYSFUNCTION 1 2.000000 105.8600 52.9300
Subtotal (Total Children Is Unduplicated) 81 158.500000 11017.7500 69.5126
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 60 57.750000 2887.5000 50.0000
COIFF-COIFFGT-IFSP CONSULT,PROF,FACE TO FACE 62 53.250000 2662.5000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 1 1.000000 25.0000 25.0000
CONIF-CONIFGT-CONSULT,ITDS,FACE TO FACE 2 2.000000 100.0000 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
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 12 15.000000 750.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 120 346.500000 17325.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 48 87.500000 4375.0000 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 5 14.500000 1043.4200 71.9600
PHY-97110-PT SESSION BY LICENSED PT 7 24.750000 1781.0100 71.9600
PHY-97110GT-PT SESSION BY LICENSED PT 1 0.500000 35.9800 71.9600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 13 34.000000 2446.6400 71.9600
TRAV-TRAVS-Travel by mile 412 24772.00000 11020.9000 0.4449
Subtotal (Total Children Is Unduplicated) 521 26871.25000 63815.4500 2.3749
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Total 27032.250000 74926.2000 2.7717
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Number of Children (Unduplicated) With at Least One Service 585
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Center 03
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 2440 18357.000000 53662.8300 53662.8300
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 72 468.000000 1533.8800 1533.8800
T 0 0.000000 0.0000 0.0000
945 8207.250000 19729.4900 0.0000
Other 0 0.000000 0.0000 0.0000
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Total 3457 27032.250000 74926.2000 55196.7100