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
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 476 353.500000 13150.2000 37.2000
TCM-T1017TL-TARGETED CASE MANAGEMENT 488 1211.000000 45046.8500 37.1981
Subtotal (Total Children Is Unduplicated) 805 1564.500000 58197.0500 37.1985
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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 2 3.500000 262.5000 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 2 4.000000 222.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 24 44.500000 3337.5000 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 39 72.000000 5400.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 12 22.500000 1687.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 98 183.500000 10184.2500 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 3 4.500000 249.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 15 28.500000 2137.5000 75.0000
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
SCREEN-T1023-SCREENING 19 19.000000 950.0000 50.0000
SPL-92526-TREATMENT OF SWALLOWING DYSFUNCTION 1 2.000000 105.8600 52.9300
Subtotal (Total Children Is Unduplicated) 191 404.000000 25942.5000 64.2141
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 71 75.750000 3787.5000 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 12 15.000000 750.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 125 374.500000 18725.0000 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 413 24773.00000 11021.3400 0.4449
Subtotal (Total Children Is Unduplicated) 544 27001.25000 67190.8900 2.4884
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Total 28969.750000 151330.4400 5.2237
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Number of Children (Unduplicated) With at Least One Service 1132
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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 2463 18399.000000 56715.3300 56715.3300
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 73 469.000000 1534.3200 1534.3200
T 0 0.000000 0.0000 0.0000
3760 10099.250000 92947.5400 0.0000
Other 2 2.500000 133.2500 0.0000
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Total 6298 28969.750000 151330.4400 58249.6500