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: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 1 1.250000 46.5000 37.2000
TCM-T1017TL-TARGETED CASE MANAGEMENT 142 254.000000 9441.6000 37.1717
Subtotal (Total Children Is Unduplicated) 143 255.250000 9488.1000 37.1718
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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 59 84.500000 6337.5000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 59 86.500000 6487.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 8 14.500000 1087.5000 75.0000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 116 167.500000 9296.2500 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) 148 453.000000 28427.8900 62.7547
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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 31021.250000 213835.9000 6.8932
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Number of Children (Unduplicated) With at Least One Service 779
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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 1117 23613.000000 114706.4500 114706.4500
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 369 530.500000 29705.8500 0.0000
T 517 6796.250000 66340.6000 66340.6000
69 77.500000 2883.0000 0.0000
Other 1 4.000000 200.0000 0.0000
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Total 2073 31021.250000 213835.9000 181047.0500