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
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 762 610.750000 22719.9000 37.2000
TCM-T1017TL-TARGETED CASE MANAGEMENT 1578 5899.750000 219373.5500 37.1835
Subtotal (Total Children Is Unduplicated) 1634 6510.500000 242093.4500 37.1851
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Screening, Eval, and Assessment,Class #02
EVAL-96111-DEVELOPMENTAL EVALUATION 22 19.750000 987.5000 50.0000
EXIT-EXIT-EXIT ASSESSMENT 13 8.500000 425.0000 50.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 3 3.500000 262.5000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 4 4.500000 337.5000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 7 10.000000 720.7500 72.0750
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 13 21.500000 1193.2500 55.5000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 129 147.000000 11025.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 139 147.500000 11062.5000 75.0000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 351 552.500000 30663.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 73 96.000000 7200.0000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 139 189.000000 14175.0000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 82 82.000000 10345.6000 126.1659
MED-99213-OUTPATIENT VISIT, EST, 15 MINS 3 3.000000 417.4700 139.1567
OCTF-97168-OT RE-EVAL EST PLAN CARE 1 1.000000 51.4100 51.4100
OCTH-97165-OT EVAL LOW COMPLEXITY 7 7.000000 359.8700 51.4100
OCTH-97167-OT EVAL HIGH COMPLEXITY 5 5.000000 257.0500 51.4100
PSTF-97164-PT RE-EVAL EST PLAN CARE 2 2.000000 102.8200 51.4100
PSTH-97161-PT EVAL LOW COMPLEXITY 8 8.000000 365.9600 45.7450
PSTH-97163-PT EVAL HIGH COMPLEXITY 5 5.000000 257.0500 51.4100
SPCH-92521-EVAL OF SPEECH FLUENCY 12 13.000000 668.3300 51.4100
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 2 2.000000 102.8200 51.4100
Subtotal (Total Children Is Unduplicated) 440 1328.250000 91008.8800 68.5179
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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 915 6534.500000 326475.0000 49.9617
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 54 269.000000 13450.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 939 6735.000000 67350.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 38 173.500000 12386.0600 71.3894
OCCT-97530HM-OT SESSION BY OT ASST 12 61.000000 3513.6000 57.6000
PHY-97110-PT SESSION BY LICENSED PT 21 88.000000 5877.0300 66.7844
PHY-97110HM-PT SESSION BY PT ASST 17 85.000000 4886.4500 57.4876
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 24 100.500000 7231.9800 71.9600
Subtotal (Total Children Is Unduplicated) 1057 14162.25000 446957.6200 31.5598
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Total 22001.000000 780059.9500 35.4557
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Number of Children (Unduplicated) With at Least One Service 1925
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Center 04
Flag Claims Units Chgs Paid
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R 86 118.000000 4671.9000 0.0000
U 0 0.000000 0.0000 0.0000
B 1782 2648.000000 106442.1000 0.0000
P 3194 9682.750000 206235.8500 198363.6400
D 56 70.750000 2851.5000 0.0000
S 1 0.750000 27.9000 0.0000
H 1592 5883.500000 295148.4400 497.8600
T 0 0.000000 0.0000 0.0000
3449 3515.750000 158961.3700 0.0000
Other 41 81.500000 5720.8900 107.9400
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Total 10201 22001.000000 780059.9500 198969.4400