CMS/EIP Fiscal Report Center: 06
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 1009 637.250000 23696.4000 37.1854
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 12 9.750000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 1927 6262.500000 232889.2500 37.1879
Subtotal (Total Children Is Unduplicated) 1964 6909.500000 256585.6500 37.1352
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Screening, Eval, and Assessment,Class #02
EXIT-EXIT-EXIT ASSESSMENT 3 6.000000 300.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 2 4.000000 300.0000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 8 12.500000 937.5000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 6 9.500000 712.5000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 1.500000 112.5000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 3 5.500000 412.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 3 5.500000 305.2500 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 8 13.000000 721.5000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 17 29.000000 2175.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 157 274.500000 20502.5000 74.6903
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 19 34.000000 2550.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 141 240.000000 18000.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 4 8.000000 600.0000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 95 172.000000 12900.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 31 56.000000 3108.0000 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 256 461.000000 25614.7500 55.5634
MED-99205-OUTPATIENT VISIT, NEW, 60 MINS 3 3.000000 334.5600 111.5200
SPCH-92521-EVAL OF SPEECH FLUENCY 1 2.000000 102.1000 51.0500
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 4 4.000000 205.6400 51.4100
SPCH-92523GT-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 5 5.000000 257.0500 51.4100
Subtotal (Total Children Is Unduplicated) 391 1346.000000 90151.3500 66.9772
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 1 1.000000 209.7100 209.7100
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 107 92.000000 4318.7500 46.9429
COIFF-COIFFGT-IFSP CONSULT,PROF,FACE TO FACE 38 33.750000 1575.0000 46.6667
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 99 83.500000 1962.5000 23.5030
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 10 12.000000 500.0000 41.6667
CONIF-CONIFGT-CONSULT,ITDS,FACE TO FACE 4 8.000000 400.0000 50.0000
CONIP-CONIP-CONSULT, ITDS PHONE 20 28.000000 643.7500 22.9911
CONOF-CONOF-CONSULT, OT, FACE TO FACE 4 3.500000 175.0000 50.0000
CONOF-CONOFGT-CONSULT,OT,FACE TO FACE 3 6.500000 325.0000 50.0000
CONOP-CONOP-CONSULT, OT, PHONE 10 16.000000 350.0000 21.8750
CONPF-CONPF-CONSULT, PT, FACE TO FACE 6 5.000000 212.5000 42.5000
CONPF-CONPFGT-CONSULT,PT,FACE TO FACE 1 0.500000 25.0000 50.0000
CONPP-CONPP-CONSULT, PT, PHONE 1 0.500000 12.5000 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 2 2.000000 100.0000 50.0000
CONSF-CONSFGT-CONSULT,SLP,FACE TO FACE 1 3.000000 150.0000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 3 4.500000 112.5000 25.0000
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 10 13.000000 650.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 1040 6874.500000 342845.0000 49.8720
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 180 563.000000 28150.0000 50.0000
INTR-T1013-INTERPRETER 8 47.500000 3120.0000 65.6842
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 1117 7748.000000 77152.6700 9.9578
OCCT-97530-OT SESSION BY LICENSED OT 30 153.500000 10623.7300 69.2100
OCCT-97530GT-OT SESSION BY LICENSED OT 3 6.500000 424.5800 65.3200
OCCT-97530HM-OT SESSION BY OT ASST 17 87.750000 4058.5900 46.2517
OCCT-97530HMGT-OT SESSION BY OT ASST 5 11.500000 647.9800 56.3461
PHY-97110-PT SESSION BY LICENSED PT 34 160.500000 10829.2000 67.4717
PHY-97110GT-PT SESSION BY LICENSED PT 11 36.250000 2582.9700 71.2543
PHY-97110HM-PT SESSION BY PT ASST 23 102.000000 5787.9700 56.7448
PHY-97110HMGT-PT SESSION BY LICENSED PT ASST 12 31.250000 1740.5900 55.6989
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 68 348.000000 23840.6600 68.5076
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 52 179.750000 12315.5100 68.5147
TRAV-TRAVS-Travel by mile 543 21768.00000 9696.7100 0.4455
Subtotal (Total Children Is Unduplicated) 1270 38430.75000 545538.3700 14.1954
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Total 46686.250000 892275.3700 19.1122
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Number of Children (Unduplicated) With at Least One Service 2071
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Center 06
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 8143 8037.750000 173976.7300 173976.7300
D 0 0.000000 0.0000 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
22050 38458.500000 711056.4100 0.0000
Other 270 190.000000 7242.2300 0.0000
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Total 30463 46686.250000 892275.3700 173976.7300