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: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 476 353.500000 13150.2000 37.2000
TCM-T1017TL-TARGETED CASE MANAGEMENT 1186 2856.500000 106254.4000 37.1974
Subtotal (Total Children Is Unduplicated) 1251 3210.000000 119404.6000 37.1977
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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 25 45.500000 3412.5000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 2 4.000000 300.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 42 77.000000 5775.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 13 24.500000 1837.5000 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 141 266.500000 14790.7500 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 4 6.500000 360.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 28 51.000000 3825.0000 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) 251 541.500000 34158.2500 63.0808
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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 30907.000000 229256.2900 7.4176
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Number of Children (Unduplicated) With at Least One Service 1416
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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 2134 1542.500000 59636.0000 0.0000
P 2552 18500.750000 62116.9900 62116.9900
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
3845 10184.000000 97663.2300 0.0000
Other 167 177.000000 6917.9500 0.0000
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Total 8821 30907.000000 229256.2900 63801.3100