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: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 473 1673.750000 62244.3000 37.1885
Subtotal (Total Children Is Unduplicated) 1057 2284.500000 84964.2000 37.1916
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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 13 8.500000 425.0000 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 34 40.000000 3000.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 46 51.500000 3862.5000 75.0000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 208 249.500000 13847.2500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 18 18.000000 1350.0000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 33 41.000000 3075.0000 75.0000
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 46 46.000000 3502.9000 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) 274 497.750000 31381.1500 63.0460
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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 939 6735.000000 67350.0000 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) 983 8189.750000 141909.9200 17.3277
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Total 10972.000000 258255.2700 23.5377
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Number of Children (Unduplicated) With at Least One Service 1667
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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 2222 8081.250000 137919.8900 138009.8900
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
2833 2774.250000 115934.0700 0.0000
Other 3 3.500000 231.3100 107.9400
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Total 5089 10972.000000 258255.2700 138487.8300