CMS/EIP Fiscal Report Center: 52
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 392 163.500000 6082.1000 37.1994
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 25 14.000000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 718 1903.250000 70437.0500 37.0088
Subtotal (Total Children Is Unduplicated) 850 2080.750000 76519.1500 36.7748
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 9 18.000000 1350.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 4 8.000000 600.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 0.500000 37.5000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 9 18.000000 999.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 186 384.000000 27800.0000 72.3958
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 3 6.000000 450.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 80 164.000000 12000.0000 73.1707
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 5 10.000000 750.0000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 22 46.000000 3280.0000 71.3043
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 2 4.000000 300.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 156 311.500000 17288.2500 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 2 4.000000 222.0000 55.5000
OCTH-97165TL-OT EVAL LOW COMPLEXITY 1 1.000000 51.4100 51.4100
OCTH-97166-OT EVAL MODERATE COMPLEXITY 2 2.000000 102.8200 51.4100
PSTH-97162GT-PT EVAL MODERATE COMPLEXITY 1 1.000000 51.4100 51.4100
PSTH-97162TL-PT EVAL MODERATE COMPLEXITY 1 1.000000 51.4100 51.4100
SCREEN-T1023-SCREENING 24 25.000000 1204.0000 48.1600
SPCH-92521-EVAL OF SPEECH FLUENCY 1 1.000000 51.4100 51.4100
SPCH-92522TL-EVAL OF SPCH SOUND PROD 2 2.000000 102.8200 51.4100
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 10 10.000000 514.1000 51.4100
SPCH-92523TL-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 8 8.000000 411.2800 51.4100
SPL-92526-TREATMENT OF SWALLOWING DYSFUNCTION 8 24.000000 1151.5300 47.9804
SPL-92526TL-TREATMENT OF SWALLOWING DYSFUNCTION 4 10.000000 529.3000 52.9300
Subtotal (Total Children Is Unduplicated) 253 1059.000000 69298.2400 65.4374
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EI Services,Class #03
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 45 51.000000 2550.0000 50.0000
COIFF-COIFFGT-IFSP CONSULT,PROF,FACE TO FACE 55 54.500000 2725.0000 50.0000
COIFP-COIFP-IFSP CONSULT, PROF, BY PHONE 16 14.500000 362.5000 25.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 52 79.250000 3962.5000 50.0000
CONIF-CONIFGT-CONSULT,ITDS,FACE TO FACE 6 5.750000 287.5000 50.0000
CONIP-CONIP-CONSULT, ITDS PHONE 1 0.250000 6.2500 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 26 32.000000 1600.0000 50.0000
CONOF-CONOFGT-CONSULT,OT,FACE TO FACE 5 2.500000 125.0000 50.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 24 57.500000 2875.0000 50.0000
CONPF-CONPFGT-CONSULT,PT,FACE TO FACE 1 1.750000 87.5000 50.0000
CONPP-CONPP-CONSULT, PT, PHONE 1 0.500000 12.5000 25.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 34 43.500000 2175.0000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 1 1.000000 25.0000 25.0000
DSTT-DSTT-DIRECT SERVICE COORDINATOR TRAVEL 135 185.500000 0.0000 0.0000
EIIF-96154-HEALTH AND BEHAVIOR INTERVENTION 5 3.500000 175.0000 50.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 398 1801.750000 89887.5000 49.8890
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 3 2.750000 137.5000 50.0000
INTR-T1013-INTERPRETER 1 1.500000 75.0000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 503 2906.000000 29060.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 30 107.000000 7483.8400 69.9424
OCCT-97530GT-OT SESSION BY LICENSED OT 3 2.750000 197.8900 71.9600
OCCT-97530HM-OT SESSION BY OT ASST 8 48.000000 2764.8000 57.6000
OCCT-97530TL-OT SESSION BY LICENSED OT 22 72.250000 5199.1100 71.9600
OCCT-97530TLGTHM-OT SESSION BY OT ASST 1 0.500000 28.8000 57.6000
OCCT-97530TLHM-OT SESSION BY OT ASST 10 56.000000 3225.6000 57.6000
PHY-97110-PT SESSION BY LICENSED PT 27 80.500000 5792.6900 71.9589
PHY-97110GT-PT SESSION BY LICENSED PT 2 2.000000 143.9200 71.9600
PHY-97110HM-PT SESSION BY PT ASST 15 68.000000 3914.0800 57.5600
PHY-97110HMGT-PT SESSION BY LICENSED PT ASST 5 7.000000 402.9200 57.5600
PHY-97110TL-PT SESSION BY LICENSED PT 27 73.750000 5307.0500 71.9600
PHY-97110TLGT-PT SESSION BY LICENSED PT 1 0.750000 53.9700 71.9600
PHY-97110TLGTHM-PT SESSION BY PT ASST 1 1.000000 57.5600 57.5600
PHY-97110TLHM-PT SESSION BY PT ASST 6 35.000000 2014.6000 57.5600
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 78 381.750000 26363.2900 69.0590
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 62 300.500000 21623.9800 71.9600
TRAV-TRAVS-Travel by mile 403 25117.00000 11175.2300 0.4449
Subtotal (Total Children Is Unduplicated) 661 31598.75000 231878.0800 7.3382
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Total 34738.500000 377695.4700 10.8725
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Number of Children (Unduplicated) With at Least One Service 999
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Center 52
Flag Claims Units Chgs Paid
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R 37 40.750000 2754.7200 0.0000
U 0 0.000000 0.0000 0.0000
B 1068 1071.000000 51655.2400 27.9000
P 885 951.750000 46501.5900 165463.6600
D 241 265.250000 14236.7600 0.0000
S 127 92.750000 3487.3500 0.0000
H 136 178.750000 11769.2800 0.0000
T 3510 28879.750000 94757.9500 88872.3300
3316 3257.500000 152495.3800 80.0000
Other 1 1.000000 37.2000 0.0000
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Total 9321 34738.500000 377695.4700 254443.8900