CMS/EIP Fiscal Report Center: 05
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 494 216.500000 8053.8000 37.2000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 94 81.500000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 489 1228.750000 45678.2500 37.1746
Subtotal (Total Children Is Unduplicated) 767 1526.750000 53732.0500 35.1937
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 2 3.000000 225.0000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 4 5.000000 375.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 8 7.500000 416.2500 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 7 11.000000 610.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 6 12.000000 900.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 18 31.500000 2362.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 2 3.500000 262.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 13 23.000000 1725.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 8 14.500000 1087.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 17 28.500000 2137.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 39 72.000000 3996.0000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 23 40.000000 2220.0000 55.5000
OCTF-97168-OT RE-EVAL EST PLAN CARE 1 1.000000 51.4100 51.4100
OCTH-97165-OT EVAL LOW COMPLEXITY 1 1.000000 51.4100 51.4100
OCTH-97166-OT EVAL MODERATE COMPLEXITY 2 2.000000 24.3000 12.1500
OCTH-97167-OT EVAL HIGH COMPLEXITY 1 1.000000 51.4100 51.4100
PSTH-97163-PT EVAL HIGH COMPLEXITY 1 1.000000 51.4100 51.4100
SPCH-92521-EVAL OF SPEECH FLUENCY 1 1.000000 51.4100 51.4100
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 1 1.000000 51.4100 51.4100
SPL-92526-TREATMENT OF SWALLOWING DYSFUNCTION 2 3.000000 94.5700 31.5233
Subtotal (Total Children Is Unduplicated) 92 262.500000 16745.0800 63.7908
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 68 64.750000 3237.5000 50.0000
COIFF-COIFFGT-IFSP CONSULT,PROF,FACE TO FACE 15 13.250000 662.5000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 10 12.000000 300.0000 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 79 116.500000 5825.0000 50.0000
CONIF-CONIFGT-CONSULT,ITDS,FACE TO FACE 2 2.000000 100.0000 50.0000
CONIP-CONIP-CONSULT, ITDS PHONE 10 3.750000 93.7500 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 54 90.000000 4500.0000 50.0000
CONOF-CONOFGT-CONSULT,OT,FACE TO FACE 7 7.000000 350.0000 50.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 8 6.500000 325.0000 50.0000
CONPF-CONPFGT-CONSULT,PT,FACE TO FACE 4 3.250000 162.5000 50.0000
CONPP-CONPP-CONSULT, PT, PHONE 1 0.500000 12.5000 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 32 23.500000 1175.0000 50.0000
CONSF-CONSFGT-CONSULT,SLP,FACE TO FACE 3 2.250000 112.5000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 2 1.500000 37.5000 25.0000
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 34 99.000000 4950.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 167 731.750000 36587.5000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 2 3.000000 150.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 517 3010.000000 30100.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 16 83.500000 5505.8500 65.9383
PHY-97110-PT SESSION BY LICENSED PT 6 19.500000 1157.4300 59.3554
PHY-97110GT-PT SESSION BY LICENSED PT 1 3.000000 65.8800 21.9600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 24 93.750000 5455.2600 58.1894
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 2 11.000000 662.9200 60.2655
TRAV-TRAVS-Travel by mile 453 42597.00000 18950.1000 0.4449
Subtotal (Total Children Is Unduplicated) 549 46998.25000 120478.6900 2.5635
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Total 48787.500000 190955.8200 3.9140
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Number of Children (Unduplicated) With at Least One Service 964
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Center 05
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 4338 46867.000000 134342.2800 134342.2800
D 1 0.250000 9.2500 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
3014 1917.250000 56492.6900 2881.4900
Other 5 3.000000 111.6000 0.0000
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Total 7358 48787.500000 190955.8200 137223.7700