CMS/EIP Fiscal Report Center: 09
Services beginning 10/01/2022 ending 12/31/2022 Date of Report:01/23/2023 Page: 1
List order: No List
Payclass Filters:OTHER
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 1 1.250000 46.5000 37.2000
TCM-T1017TL-TARGETED CASE MANAGEMENT 90 180.250000 6700.4000 37.1728
Subtotal (Total Children Is Unduplicated) 91 181.500000 6746.9000 37.1730
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 3 4.000000 300.0000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 2 3.000000 225.0000 75.0000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 5 7.000000 388.5000 55.5000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 30 46.000000 3450.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 37 56.500000 4237.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 4 7.500000 562.5000 75.0000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 65 98.000000 5439.0000 55.5000
NUTR-97802-NUTRITIONAL EVAL, INITIAL 1 4.000000 200.0000 50.0000
NUTR-97803-NUTRITIONAL EVAL, FOLLOW-UP 13 78.000000 3900.0000 50.0000
PSTH-97161-PT EVAL LOW COMPLEXITY 1 1.000000 51.4100 51.4100
SPCH-92521-EVAL OF SPEECH FLUENCY 3 3.000000 154.2300 51.4100
Subtotal (Total Children Is Unduplicated) 94 308.000000 18908.1400 61.3901
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 19 33.500000 1675.0000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 16 19.000000 475.0000 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 2 2.000000 100.0000 50.0000
CONIF-CONIFGT-CONSULT,ITDS,FACE TO FACE 1 1.000000 50.0000 50.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 2 2.000000 100.0000 50.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 1 1.000000 50.0000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 1 1.000000 50.0000 50.0000
CONSF-CONSFGT-CONSULT,SLP,FACE TO FACE 1 1.000000 50.0000 50.0000
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 2 5.000000 250.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 260 1456.000000 71114.7300 48.8425
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 3 5.000000 50.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 45 222.000000 15975.1200 71.9600
PHY-97110-PT SESSION BY LICENSED PT 58 383.000000 27458.7900 71.6940
PHY-97110GT-PT SESSION BY LICENSED PT 6 39.000000 2806.4400 71.9600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 100 597.500000 42996.1000 71.9600
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 1 9.000000 647.6400 71.9600
TRAV-TRAVS-Travel by mile 491 27536.00000 12071.0900 0.4384
Subtotal (Total Children Is Unduplicated) 648 30313.00000 175919.9100 5.8034
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Total 30802.500000 201574.9500 6.5441
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Number of Children (Unduplicated) With at Least One Service 724
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Center 09
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 1114 23608.000000 114331.4500 114331.4500
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 215 321.500000 17996.6000 0.0000
T 517 6796.250000 66340.6000 66340.6000
67 72.750000 2706.3000 0.0000
Other 1 4.000000 200.0000 0.0000
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Total 1914 30802.500000 201574.9500 180672.0500