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: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 567 248.500000 9244.2000 37.2000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 118 105.000000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 557 1516.750000 56384.2000 37.1744
Subtotal (Total Children Is Unduplicated) 862 1870.250000 65628.4000 35.0907
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 6 8.500000 637.5000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 2 2.500000 187.5000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 5 6.000000 450.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 9 9.500000 527.2500 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 9 14.500000 804.7500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 17 31.000000 2325.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 33 52.500000 3937.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 3 5.000000 375.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 17 30.000000 2250.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 9 15.500000 1162.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 32 49.500000 3712.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 55 98.500000 5466.7500 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 45 71.000000 3940.5000 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) 143 405.000000 26204.0800 64.7014
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 69 65.000000 3250.0000 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 168 732.750000 36637.5000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 2 3.000000 150.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 541 3046.000000 30460.0000 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 478 43437.00000 19323.4300 0.4449
Subtotal (Total Children Is Unduplicated) 575 47875.50000 121274.5200 2.5331
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Total 50150.750000 213107.0000 4.2493
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Number of Children (Unduplicated) With at Least One Service 1061
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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 4502 47831.750000 144433.4700 144433.4700
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
3466 2315.750000 68552.6800 3045.1300
Other 5 3.000000 111.6000 0.0000
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Total 7974 50150.750000 213107.0000 147478.6000