CMS/EIP Fiscal Report Center: 04
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: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 729 587.750000 21864.3000 37.2000
TCM-T1017TL-TARGETED CASE MANAGEMENT 437 1509.250000 56124.9000 37.1873
Subtotal (Total Children Is Unduplicated) 998 2097.000000 77989.2000 37.1908
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Screening, Eval, and Assessment,Class #02
EVAL-96111-DEVELOPMENTAL EVALUATION 22 18.750000 937.5000 50.0000
EXIT-EXIT-EXIT ASSESSMENT 12 8.000000 400.0000 50.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 2 2.500000 187.5000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 2 2.000000 140.2500 70.1250
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 1 0.500000 27.7500 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 5 10.500000 582.7500 55.5000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 25 29.500000 2212.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 36 40.500000 3037.5000 75.0000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 170 202.000000 11211.0000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 14 14.500000 1087.5000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 23 28.500000 2137.5000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 41 41.000000 3122.1500 76.1500
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 1 1.000000 31.4700 31.4700
PSTH-97161-PT EVAL LOW COMPLEXITY 3 3.000000 154.2300 51.4100
PSTH-97163-PT EVAL HIGH COMPLEXITY 3 3.000000 154.2300 51.4100
SPCH-92521-EVAL OF SPEECH FLUENCY 2 2.000000 102.8200 51.4100
Subtotal (Total Children Is Unduplicated) 229 407.250000 25526.6500 62.6805
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 34 59.750000 2987.5000 50.0000
CONOF-CONOFGT-CONSULT,OT,FACE TO FACE 1 1.000000 50.0000 50.0000
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 12 55.000000 2750.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 161 1138.500000 56925.0000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 15 90.000000 4500.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 936 6727.000000 67270.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 3 23.500000 1691.0600 71.9600
OCCT-97530HM-OT SESSION BY OT ASST 3 16.000000 921.6000 57.6000
PHY-97110-PT SESSION BY LICENSED PT 3 10.500000 755.5800 71.9600
PHY-97110HM-PT SESSION BY PT ASST 6 26.000000 1496.5600 57.5600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 6 34.500000 2482.6200 71.9600
Subtotal (Total Children Is Unduplicated) 980 8181.750000 141829.9200 17.3349
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Total 10686.000000 245345.7700 22.9596
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Number of Children (Unduplicated) With at Least One Service 1599
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Center 04
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 2219 8073.250000 137839.8900 137929.8900
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 31 113.000000 4170.0000 370.0000
T 0 0.000000 0.0000 0.0000
2586 2496.250000 103104.5700 0.0000
Other 3 3.500000 231.3100 107.9400
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Total 4839 10686.000000 245345.7700 138407.8300