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
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 1009 637.250000 23696.4000 37.1854
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 12 9.750000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 839 2653.750000 98718.8500 37.1998
Subtotal (Total Children Is Unduplicated) 1403 3300.750000 122415.2500 37.0871
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Screening, Eval, and Assessment,Class #02
EXIT-EXIT-EXIT ASSESSMENT 2 4.500000 225.0000 50.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 1 1.500000 112.5000 75.0000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 1 1.500000 83.2500 55.5000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 8 14.500000 1087.5000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 1 1.500000 112.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 6 10.500000 787.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 4 7.500000 562.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 1 1.500000 83.2500 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 14 25.500000 1415.2500 55.5000
MED-99205-OUTPATIENT VISIT, NEW, 60 MINS 1 1.000000 142.2300 142.2300
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) 30 80.500000 5176.2700 64.3015
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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 106 91.000000 4268.7500 46.9093
COIFF-COIFFGT-IFSP CONSULT,PROF,FACE TO FACE 38 33.750000 1575.0000 46.6667
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 98 83.000000 1950.0000 23.4940
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 369 2381.500000 118275.0000 49.6641
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 53 160.000000 8000.0000 50.0000
INTR-T1013-INTERPRETER 8 47.500000 3120.0000 65.6842
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 1117 7742.000000 77150.0000 9.9651
OCCT-97530HM-OT SESSION BY OT ASST 2 5.500000 316.8000 57.6000
OCCT-97530HMGT-OT SESSION BY OT ASST 1 3.000000 172.8000 57.6000
PHY-97110-PT SESSION BY LICENSED PT 3 19.750000 1403.1900 71.0476
PHY-97110HMGT-PT SESSION BY LICENSED PT ASST 1 4.000000 230.2400 57.5600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 18 88.750000 6364.7600 71.7156
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 4 6.250000 449.7500 71.9600
TRAV-TRAVS-Travel by mile 1 20.000000 8.9000 0.4450
Subtotal (Total Children Is Unduplicated) 1179 10789.50000 227151.1500 21.0530
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Total 14170.750000 354742.6700 25.0334
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Number of Children (Unduplicated) With at Least One Service 1858
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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 7920 7885.500000 164742.7700 164742.7700
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
8064 6095.250000 182757.6700 0.0000
Other 270 190.000000 7242.2300 0.0000
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Total 16254 14170.750000 354742.6700 164742.7700